Yesterday’s post was not really about Avastin, but about medical journalism and how patients’ voices are handled by the media.
L. Husten, writing on a Forbes blog, cried that the press fawned, inappropriately, over patients’ words at the FDA hearing last week, and that led him to wonder why and if journalists should pay attention to what people with illness have to say, even if their words go against the prevailing medical wisdom.
There’s a fair amount of controversy on this. For sake of better discussion in the future, I think it best to break it up into 3 distinct but inter-related issues:
1. About health care journalism and patients’ voices:
A general problem I perceive (and part of why I started blogging) is how traditional medical journalists use patients’ stories to make a point. What some of my journalism professors tried to teach me, and most editors I’ve dealt with clearly want, is for the reporter to find a person with an illness, as a lead, and then tell about the relevant news, and provide some expert commentary – with at least one person speaking on each “side” of the issue, of course – and then end the story with some bit about the patient and the future.
I argue that this form of medical journalism reduces the patient to an object, used by the story-teller in order to capture the reader’s attention. So, with exceptions and always with the person’s consent, I prefer to offer my own story, from my perspective, so as not to use the patient as a vehicle or literary device.
So it appears that Husten is OK with using patients’ voices to tell a story (and sell papers/clicks?), but not with presenting their views unfiltered if they don’t mesh with the party line or a particular point an editor wants to make. This lies at the center of the journalism issue.
(As an aside, a few recent published studies have found value in analyses of patient-reported symptoms, unfiltered even by their doctors.)
2. About Avastin:
My impression is that some beast cancer advocates, including a National Breast Cancer Coalition representative who spoke at the FDA hearing, have chosen to “take the hit” on this particular issue because they need and want to appear rational. The straightforward-seeming argument is that the data show Avastin doesn’t work and is often harmful, so it shouldn’t be FDA-approved for women with metastatic BC. From the perspective of a BC advocacy group, it may not be worth pushing for a drug that helps only around 5% of patients.
The problem is there’s no biomarker for Avastin responsiveness, because this drug doesn’t target a particular genetic marker. Rather it works by cutting the blood supply, which could vary even within a particular patient’s mets in different organs. The only way to test if Avastin works in a patient is to give the drug, with informed consent, and see how it goes. Unlike, say, a bone marrow transplant, which runs in the range of hundreds of thousands of dollars and, once done, is irreversible, you can give one dose of Avastin and stop it, or two and stop it, if it doesn’t work or it is not well-tolerated.
Based on my experience as an oncologist and patient who’s received some risky interventions, I don’t think Avastin is more toxic than many or even most cancer drugs. Rather, its side effects have been heavily pushed by the media and public health/epidemiology academics in the past two years, who perhaps wish to make a larger point about this costly drug and evidence based medicine (EBM).
3. About evidence-based medicine: I’m in favor of EBM, especially in principle. The problem is that published medical data is too-often flawed and also, that some patients are, really, outliers.
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The problem is that you can’t just take a dose or two of Avastin and see if it helps — or worse has a bad adverse event.
Avastin for breast cancer, as for all cancers for which it has FDA approval, must be given with chemotherapy. The chemo/Avastin combination is given until the cancer progresses.
If cancer progresses rapidly — at the next scan or two — you stop the regimen, both Avastin and chemo, and go on to something else. Other regimens are available for second-line treatment of metastatic breast cancer.
If cancer doesn’t progress, the regimen continues. The problem is that the evidence doesn’t show whether it is the chemo that is working or if Avastin boosts chemo. Several trials have shown a very small increase in time to progression with Avastin and no survival benefit.
The nasty side effects aren’t like chemo where you immediately feel sick. Holes in the intestinal tract, which can kill you, heart attacks, strokes, (also potentially deadly) can come along at any point in treatment and are related directly to Avastin, not the chemo.
So you know the risks and the very small chance of benefit. The drug is on the market.
Patients as individuals can decide for themselves IF they know the real risks and the real benefit.
The FDA needs to make evidence-based decisions for the public.
And journalism needs to tell the entire story. Leading with only optimistic stories isn’t acceptable.
Kate, In case it wasn’t otherwise clear, Avastin is given for BC in combination with a chemotherapy drug, typically a taxane. In a previous post — http://t.co/IwbJ5Cn, I wrote on how Avastin is used with a chemo “backbone.” Otherwise, like a traditional combination chemotherapy, Avastin can be tried and stopped.