‘Cutting For Stone,’ and Considering the Experience of Practicing Medicine

A short note on Cutting for Stone, a novel I’ve just read by Dr. Abraham Verghese. He’s an expert clinician and professor at Stanford. The author uses rich language to detail aspects of Ethiopian history, medicine and quirks of human nature. The book’s a bit long but a page-turner, like some lives, taking a strange and sometimes unexpected course.

For today I thought I’d mention one passage that haunts me. It appears early on, when the protagonist, a man in middle age reflects on his life and why he became a physician:

My intent wasn’t to save the world as much as to heal myself. Few doctors will admit this, certainly not young ones, but subconsciously, in entering the profession, we must believe that ministering to others will heal our woundedness. And it can. But it can also deepen the wound.

The point is, a physician may be immersed in his work in a manner that he is, in effect, “addicted” to practicing medicine – a term Verghese uses later on in the book. There’s an emotional boost, or relief, some doctors glean by their daily tasks. An example he gives is a surgeon who feels better upon seeing his patient, who’d been sick, recovering nicely after an operation. This applies in other fields, including oncology.

I get this. It’s an under-discussed aspect of being a doctor, articulated well in some characters’ pathology and passion.

More on this, later, elsewhere –

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Final Word on Avastin, and Why We Need Better Physicians

Today’s breaking breast cancer news is on Avastin. The FDA has just announced, formally, that it will rescind approval for the drug’s use in people with metastatic breast cancer. Commissioner Dr. Margaret Hamburg writes this her statement:

I know I speak on behalf of the many physicians that have been involved with this issue here at the Food and Drug Administration and elsewhere in saying that we encourage patients, and those who support them, to ask hard questions and demand explanations concerning the drugs that are recommended to treat serious illnesses.

On this much I agree with Dr. Hamburg – that patients and others, including doctors who prescribe treatments to patients with likely incurable illnesses, and all medical conditions, for that matter, should ask hard questions.

Others have already, immediately expressed that the FDA did the right thing. Because they think the FDA’s decision was rational, and it was. Likely there’ll be an editorial in the paper I usually read, celebrating the victory of reason over anecdote. The WSJ, whose words tend to align more with business interests, will likely be critical. Opponents of health care reform will, inappropriately and mistakenly, use this as an example of rationing, which it isn’t.

The fact is that many, and possibly most, medical treatments are given in the absence of studies to justify their use. So you might ask, instead, why give chemotherapy to most stage IV cancer patients. Or why give it in the adjuvant setting? Apart from some tumors, like some kinds of lymphoma and leukemia, and common breast and testicular cancers, and a few others, when carefully measured the benefit is often slim.

What I think is that Avastin is a scapegoat of sorts, a costly drug not particularly worse than many others, nor better, and that helps a small minority of women with a lethal disease for reasons their doctors can’t predict or explain.

We experiment, on insurance and Medicare dollars, with so many costly treatments. Bone marrow transplants, at a cost of hundreds of thousands of dollars per patient, for example, are given to some with little formal proof of benefit for the approved indications. But there’s a lobby for these treatments. Support comes from hospitals profiting from transplant procedures and, more subtly, from academic physicians who’ve built careers in that field and write papers about their benefits, complications and management. I might cite other complex, costly and unproved examples in oncology, surgery and other fields of medicine, but that’s not the real point for today.

What I wonder is, ironically, because the data on Avastin were collected so carefully, that its lack of effectiveness over a population of women was better-documented than has been the lack of evidence for other drugs and regimens. Besides, there’s no group of hospitals and doctors whose profit and livelihood, respectively, depends on giving Avastin to just a few people with metastatic breast cancer. There was just Genentech, an easy big-Pharma target, and a few women, pleading for continued access to a drug that’s helped to keep them alive.

(I wonder, also, had those patients who testified been men, would their words have been taken more seriously?)

Meanwhile, doctors can keep giving Avastin to patients with other forms of cancer, for which its efficacy is not so different as you might think. Like any drug, this drug’s response varies from patient to patient for every tumor type that it might be given. And the physicians can still give Avastin, as the commissioner points out in her decision, to women who can pay for it, by circumstances of their particular insurance, or good fortune of wealth. But some of these women’s families will be hurt hard by this FDA decision. Most are in the 99%.

And so maybe what we really need are better doctors, not only in oncology, who would carefully monitor patients when they give any and every medical treatment and stop it if it’s not working, and continue only if it helps, and would communicate and obtain informed consent through meaningful discourse.

If we had that, we’d save a lot of money, and get better care.

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President Obama Talks About Smoking and Tobacco

Today’s ML comes straight from the Oval Office. President Obama talks about smoking, and how hard it is to stop, and what can be done to reduce the use and long-term health consequences of tobacco.

What I like about this Presidential health advisory:

He credits the ACS, which is sponsoring a smokeout today.

He’s clear about the problem’s scope: “Today 46 million Americans are still hooked, and tobacco remains the leading cause of preventable, early deaths in this country.”

He doesn’t deny his own history. His experience lends credibility to his words; he understands how hard it is to stop smoking once you’ve begun.

He considers a solution: “We also know that the best way to prevent the health problems that come from smoking is to keep young people from starting in the first place.”

He reflects on the power of tobacco companies, which are fighting requirements for candid warning labels on their products.

All in 1 minute and 34 seconds!

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iPod Therapy – Why Not Prescribe It?

Yours truly, the author of Medical Lessons, is listening to music while she writes. A live version of the Stones’ “Silver Train” has just come on, and she’s happily reminded of something that happened 30 years ago. Distracting? Yes. Calming? Yes. Paradoxically helps to keep me on track? Yes.

My iPod keeps my mind from wandering further. And it lifts my mood.

And so here, on my blog, which is not peer-reviewed or anything like that, I put forth the medical concept of “iPod therapy.”

“When you’re weary, feeling small…” Music can help.

Today’s news reports that 1 in 5 Americans take drugs for psychiatric conditions. That sounds like a lot to me, but I’m no pharmaceutical surveyor. Of course many people need and benefit from medical help for depression and other mental illnesses.

But, in all seriousness, I wonder how many people might use music like a drug to keep them relaxed, happy, alert…

Why not prescribe music? It works for me, n=1.

Maybe doctors should be recommending iPods, or radios, or Pandora to some of their patients who are feeling down. I hope an academic psychiatrist somewhere, without ties to Apple or Pandora or Bose or other relevant party is coordinating a careful, prospective study of this promising and relatively inexpensive intervention.

As best I can tell, music is non-addictive. Except that if I had to live without it, I’d start humming, or maybe singing, which might be detrimental to those who live near.

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Thoughts, on Getting My Photo Taken at a Medical Appointment

A funny thing happened at my doctor’s appointment on Friday. I checked in, and after confirming that my address and insurance hadn’t changed since last year, waited for approximately 10 minutes. A worker of some sort, likely a med-tech, called me to “take my vitals.”

She took my blood pressure with a cuff that made my germ-phobic self run for self-regulation, i.e. I stayed quiet and didn’t express my concern about the fact that it looked like it hadn’t been washed in years. I value this doctor among others in my care, and I didn’t want to complain about anything. Then the woman took my weight. And then she asked if she could take my picture, “for the hospital record.”

I couldn’t contain my wondering self. “What is the purpose of the picture?” I asked.

“It’s for the record,” she explained. “For security.”

I thought about it. My picture is pretty much public domain at this point in my life, a decision I made upon deciding not to blog anonymously. Besides, most everyone at the medical center used to know me, including the receptionists, janitors, cafeteria cashiers, nurses’ aides, social workers, deans, full professors, geneticists, fellows in surgery and old-time voluntary physicians, among others who work there. So why didn’t I want this unidentified woman who works in my oncologist’s office to take my picture?

It made me uncomfortable, and here’s the reason: My picture is a reminder that, without it, I might be like any other patient in the system. They (administrators?, nurses, other docs, maybe even my future doctors) will need or want the picture to recall and be certain who Elaine Schattner is.

Don’t get me wrong. I agreed to the photo after all of maybe 20 seconds deliberating. (And my doctor was, I soon learned, duly informed I’d “had an issue” with it. Was that for just asking the reason?) The unidentified med-tech person used an oddly small, ordinary pink camera to complete her task.

When I met with my doctor, she explained that the photo is for security and, essentially, to reduce the likelihood of errors. The hospital has records of so many thousands of patients, many who have similar or identical names. There are good reasons to make sure that your notes on “Sally Smith” are entered into the chart of “Sally Smith” who is your patient.

It’s understandable. I remember when at the nurses’ station there’d be a sign (on “our” side) saying something like “CAREFUL: Anna Gonzalez in 202, Alma Gonzalez in 204b,” or something like that.

Patients blur.

It’s hard, veritably impossible, for most doctors and nurses to keep mental track of all of the patients they’ve ever seen and examined. There’s utility in the new system. Yes, it’s a good idea for a doctor, say upon receiving a call from a woman she hasn’t seen in 3 or 6 or 9 years, to see her picture in the chart, as a reminder.

But I hope my doctors know who I am, and not just what I look like in the image.

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Magic Johnson is Alive 20 Years after Announcing He Had HIV

Yesterday’s Washington Post Sports has a clip from CNN, 20 years ago, when basketball star Magic Johnson announced on TV that he had HIV, the virus that causes AIDS. The date was Nov 7, 1991.

“Where were you when Magic made his announcement? What were your thoughts on Johnson and HIV/AIDS that day and how have they changed?” asks Matt Brooks in his column.

I can’t quite recall where I was. Probably I was at the hospital working, possibly even taking care of a patient with HIV. But I do remember thinking how much courage it must have taken for him to come out with it.

He understood, likely, that he would die soon, and his doctors probably thought the same. There were only two antiviral drugs approved for HIV back then. There was so much stigma, and fear.

Today you can see and listen to him in an interview on ESPN.

It’s great to see Magic Johnson back in the news, even if it’s (just) in a sports sections, and to be reminded that he’s alive, doing OK. The condition we thought was a death sentence has become a chronic illness, with so many drugs available for treatment it’s hard to keep track.

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On Alcohol and Breast Cancer, Guilt, Correlations, Fun, Moderation, Doctors’ Habits, Advice and Herbal Tea

Few BC news items irk some women I know more than those linking alcohol consumption to the Disease. Joy-draining results like those reported this week serve up a double-whammy of guilt: first – that you might have developed cancer because you drank a bit, or a lot, or however much defines more than you should have imbibed; and second – now that you’ve had BC, the results dictate, or suggest at least, it’s best not to drink alcohol.

The problem is this: If you’ve had BC and might enjoy a glass of wine, or a margarita or two at a party, or a glass of whiskey, straight, at a bar, or after work with colleagues, or when you’re alone with your cat, for example, you might end up feeling really bad about it – worse than if you had only to worry about the usual stuff like liver disease and brain damage, or if you could simply experience pleasure like others, as they choose.

The newly-published correlative data, in the Nov 2 issue of JAMA, are clear. The findings, an offshoot of the Nurses’ Health Study, involve over 105,000 women monitored from 1980 until 2008. The bottom line is that even low levels of alcohol consumption, the equivalent to 3-6 drinks per week, are associated with a statistically significant but slight increase in breast cancer incidence. And the more a woman drinks, the more likely she is to develop breast cancer.

All things considered, it might be true that alcohol is a breast carcinogen, as Dr. Steven Narod calls it in the editorial accompanying the research study. Still, there’s no proof of cause and effect: Other factors, like consuming lots of food or perhaps some yet-unidentified particularity about living in communities with abundant food and alcohol, are potential co-variables in this story. But what if it is true?

From the editorial:

These findings raise an important clinical question: should postmenopausal women stop drinking to reduce their risk of breast cancer? For some women the increase in risk of breast cancer may be considered substantial enough that cessation would seem prudent. However, there are no data to provide assurance that giving up alcohol will reduce breast cancer risk.

How I see it is this: Everything’s best in moderation, including enjoyment of one’s life. You work, you rest, you have some fun.

This evidence is not like the strong data linking cigarettes to smoking that officials sat on for a few decades under the influence of the tobacco industry. This is a plausible, mild, and at this point well-documented correlation.

I don’t deny the sometimes harmful effects of alcohol; no sane physician or educated person could. But if you have a glass of wine, or even a second, so long as you don’t drive a car or work while affected, I don’t see it as anyone’s business but your own. More generally, I worry about how much judging there is by people who behave imperfectly, and how that can make individuals who are good people in most ways feel like they don’t deserve to be happy or enjoy their lives.

Women, in my experience, are generally more vulnerable to the put-downs of others. And so my concern about the BC-alcohol link is that this will, somehow, be used, or have the effect of, making survivors or thrivers or women who haven’t even had breast cancer feel like they’re doing the wrong thing if they go to a party and have a drink. And then they’ll feel badly about themselves.

Really I’m not sure what more to say on this loaded topic, except that it points to the deeper and broader ethical dilemma of doctors who are not all perfect examples of moderation, expecting and asking other people to change their personal habits when they themselves like to go out and have fun, and drink, at parties, or have wine in the evenings over dinner in the privacy of their homes.

How shall I resolve this post?

Last night I sipped Sleepytime tea, manufactured by Celestial Seasonings, before reading a book. The stuff is said to be 100% natural, with “a soothing blend of chamomile, spearmint and lemongrass.” I tried it first a few weeks ago and, by a placebo effect or through real chemistry, it helps me sleep more soundly.

I’ve absolutely no idea what are the effects of “Sleepytime tea” on breast cancer. It might help, it might hurt, or it might do nothing at all.

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A Poster for Healthy Eating, 1940s Style

A curious diagram appeared in the most recent NEJM, in a perspective on U.S. dietary guidelines. It’s a USDA food wheel from the early 1940s. With Twitter-like style, it says: “For Health…eat some food from each group…every day!

The details are rich: “butter and fortified margarine” constitute 1of the 7 groups. Further inspection-worthy, IMO.

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HCR Law Requires Insurers to Cover Routine Care for Patients Participating in Clinical Trials

Something I learned at the MBCN conference is that the Patient Protection and Affordable Care Act of 2010 (PPACA, a.k.a. HCR), will require that private insurance companies cover the routine costs of medical care for patients participating in approved clinical trials.

Medicare does so already, said Dr. Tatiana Prowell, an oncologist on the Johns Hopkins faculty who spoke at the meeting. Indeed, it says so on a CMS document.

The Association of Community Cancer Centers provides a readable section on the relevant changes, including definitions of “routine costs” and what are “approved trials” according to the new law.

All for now –

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Mammograms Could Save More Lives Than You Might Think

I’m wondering is how to bring mainstream health journalists and women who are, lately, choosing not to have mammograms, to their senses about a persuasive but flawed argument put forth by a Dartmouth epidemiologist and others in a crew of seemingly like-minded, hopefully well-intentioned, some perhaps tenure-seeking and others grant-needing, circulatory bias-confirming academics who meet and discuss and write about the so-called dangers of mammography.

Maybe some doctors and journalists think they’re doing the right thing by informing a naïve body of women who, in the words of an LA Times writer today, think only correlative and simple thoughts.

From Screening mammograms save fewer lives than you think:

If you or someone you know discovered she had breast cancer thanks to routine mammography screening, and if you or that friend with breast cancer got treatment and today is cancer-free, it’s natural to assume that the mammogram was a life-saver.

But odds are, it wasn’t….

First things first: the title makes an assumption about what I, or you, or any reader, thinks.

Second, the story offers two factoids: first – that over 75% of women diagnosed with BC by screening mammography wouldn’t have died from the cancer if they hadn’t had mammography; and second – that no more than 25% of those same women can rightly credit a mammogram for saving their lives. But this is just one stat, or falsehood, based on the true, assumption-free relationship between 75% and 25%.

Dr. H. Gilbert Welch, who recently likened mammography-taking to gambling, plays freely with impressive-sounding information sources. He and his coauthor used data from the NCI. Seemingly hard to argue with those kinds of numbers. But they used old data, again, and employ numerous assumptions (what the authors call generous, but I wouldn’t) to render calculations and “prove” their point published in the Archives of Internal Medicine.

The manipulative tone is set in the paper’s abstract:

“…We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved…

Simple? Don’t you believe it.

There’s a Well post in the New York Times today covering the same Archives of Internal Medicine article. Not surprisingly, this draws positive feedback in the comments and Twitter-chatter. Some of the more understandable discussion comes from women with metastatic disease whose tumors were missed by screening mammography. Notably, neither paper quotes an oncologist.

Here in the U.S. where we do spend too much on health care, we all know women whose breast tumors were missed by screening mammograms. This happens, and it’s awful, but it doesn’t and certainly shouldn’t happen so often as some doctors seem to think. Extrapolating from personal observations to draw conclusions about a procedure’s value is flawed reasoning, either way.

I agree with many of Dr. Susan Love’s school, and most of the NBCC agenda, and others that say breast cancer prevention would be better than treatment. How could I not?

But until there’s a prevention for BC, which I’m sorry to report is unlikely to happen before 2020, especially because it’s really 15 or 20 or maybe even more diseases that would, presumably, need distinct methods of prevention, and until there are better, less damaging and less costly remedies, mammography may be the best way for middle-aged women to avoid the debilitating and lethal effects of late-stage disease. And for society to avoid the costs of that condition and its treatments, which are huge.

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post shortened 12/18/12

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Reading About Thinking (on D. Kahneman’s Ideas on Perceptions of Knowledge)

An article appeared in yesterday’s NYT Magazine on the hazards of over-confidence. The Israeli-born psychologist (and epistemologist, I’d dare say), Nobel laureate and author Daniel Kahneman considers how people make decisions based on bits of information that don’t provide an adequate representation of the subject at hand. He recounts how poorly, and firmly, army officers evaluate new recruits’ leadership potential and how brash, rash or naive traders maintain investors’ trust while weighing stocks to buy or sell.

The point, as I understand it, is that individuals, including influential and powerful people, routinely make recommendations without having adequate knowledge to support their decisions. And they do so comfortably.

Men are afflicted by overconfidence more than women, he suggests, although I’m not sure he’s right on this point. In the article, he uses reckless investors who rack up stock losses as an example: Guys are more likely to lose lots of money than are women who, in general, are more cautious in their investments and, perhaps, less confident about their predictions.

I’ll have to read Kahneman’s forthcoming book, Thinking Fast and Slow, to learn more about his views on differences between men and women’s cognitive biases.

Nearing the end of the magazine piece, Kahneman alludes to medical decisions. He suggests that some doctors, perhaps through life-and-death sorts of feedback on the outcomes, may be distinguished by their capacity to gauge their own judgment skills.

He writes:

We often interact with professionals who exercise their judgment with evident confidence, sometimes priding themselves on the power of their intuition…

And asks:

How do we distinguish the justified confidence of experts from the sincere overconfidence of professionals who do not know they are out of their depth? We can believe an expert who admits uncertainty but cannot take expressions of high confidence at face value…people come up with coherent stories and confident predictions even when they know little or nothing. Overconfidence arises because people are often blind to their own blindness.

And broaches the topic of doctors’ expertise:

True intuitive expertise is learned from prolonged experience with good feedback on mistakes. You are probably an expert in guessing your spouse’s mood from one word on the telephone…true legends of instant diagnoses are common among physicians….Anesthesiologists have a better chance to develop intuitions than radiologists do….

I read this article on the train last evening and found it fascinating, so much so I hope I can find time to read the full book. Even though Kahneman is just a single human, and necessarily biased like the rest of us, he’s got some interesting and well-articulated ideas. I’m curious, in particular, if he’ll further dissect the critical thinking pathways among different doctor types.

In my experience, we’re a variable bunch. But who knows?

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3 Differences between Prostate and Breast Cancer Screening

Days ago, the USPSTF issued a new draft for its recommendations on routine PSA measurements in asymptomatic men. The panel’s report is published in the Annals of Internal Medicine. The main findings are two: first, the absence of evidence that routine PSA testing prolongs men’s lives, and second, that PSA evaluation may, on balance, cause more harm than good.

Not surprisingly, there’s been considerable coverage of this by the media, and some controversy. For decades, many men have had their PSA checked, knowingly or not, by their physicians. The PSA test  measures the level of Prostate Specific Antigen, a protein produced and sometimes secreted by prostate cells, normal, inflamed or malignant, into the bloodstream.

As an oncologist, I don’t find the panel’s recommendations surprising. There’s never been strong data to support the hypothesis that routine PSA testing reduces mortality for men in any age group. Prostate cancer is often indolent, a slow-growing kind of tumor for which a “watch and wait” approach may be best, especially when it occurs in elderly men who are most likely, even in the absence of treatment, to die of another cause. The complication rate of prostate surgery is fairly high, although this “cost” of screening likely varies, depending on the skill of the surgeon. Still, and understandably, there are men who swear by this measurement, whose lives have been, in some cases, saved by early detection of a high-grade tumor upon screening.

For today, I’d like to consider some key differences between breast and prostate cancers, and the potential value of screening:

1. Breast cancer tends to affect younger patients than prostate cancer.

Based on SEER data, the median age of a breast cancer diagnosis in the U.S. is 61 years. The median age of death from breast cancer is 68 years. For prostate cancer, the SEER data show a median age of 67 years at diagnosis, and for death from prostate cancer, 80 years.

So the potential number of life-years saved by early detection and intervention is, on average, greater for breast cancer than for prostate cancer.

2. Screening for breast cancer has improved over the past 25 years.

Because the blood test for PSA hasn’t changed much in decades, it’s reasonable to consider studies and long-term survival curves based on data going back to the 1980s.

Mammography, by contrast, is much safer and better than it was 25 years ago, for various reasons: increased regulation of mammography facilities (more care with the procedure, better training and credentialing of technicians) according to the FDA’s Mammography Quality Standard Acts Program ; development of ultrasound methods to supplement mammograms in case of suspicious lesions (lessens the false positive rate overall); the advent of digital technology (lessens the false positive rate in younger women and others with dense breasts); more breast radiology specialists (expertise).

The data reviewed by the USPSTF in issuing their 2009 recommendations for BC screening were decades old, and, as I’ve considered previously, irrelevant to modern medical practices. A recent article in the NEJM points to the problem of the panel’s reliance on the Age trial for women in their 40s. That trial involved the obsolete method of single-view mammography.

3. Mammography involves a woman’s consent (in the absence of dementia – a separate ethical issue).

A woman knows if she’s getting a mammogram. She may not ask sufficient questions of her doctor, or her doctor may not answer them well, but in the end she does or doesn’t enter into a radiology room, volitionally. She decides to get screened, or not. She can choose to have a mammogram every year, or every other year, or not at all.

There’s no ethical problem, as reported for some men, of patients learning they have an abnormal PSA, after blood was drawn indiscriminately, without their knowing the test was being performed.

This perspective might, and should, later extend to consider additional differences between these two kinds of malignancies (each of which is really a group of cancer subtypes), a fuller discussion of the impact of treatment on survival for each type, and the relative risks of screening due to differential complication rates of biopsies and other procedures.

To be clear, there’s no perfect screening test for either cancer type. Far from it. But the merits and risks of each procedure should be weighed separately, and with care.

All for today.

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What Is a Cancer Metastasis?

A metastasis refers to a lump of cancer cells that’s physically separated from the original tumor. A metastasis can be local, like when colon cancer spreads to a nearby lymph node in the gut, or distant, as when lung cancer cells generate tumors in the adrenal gland, liver, bone or brain.

Sometimes metastases cause serious damage in the organs where they’ve settled. For instance, brain “mets” can result in impaired thinking, personality changes, blindness or seizures. Liver metastases, if large enough, can result in hepatic (liver) failure. Bone mets can lead to anemia and other blood cell deficiencies if the marrow becomes filled with malignant cells instead of normal ones.

A common source of confusion is that when cancer moves from one body part to another, it’s still referred to by its site of origin.  For example, if breast cancer spreads to the liver or bone, it is still called breast cancer and most often treated as such. In general it’s the type of malignant cell, rather than the affected organ, that guides therapy.

Notes on usage: The plural is “metastases.” When someone has metastatic disease, that means their cancer has spread from the primary site to another. Oncologists don’t usually apply these terms to leukemia or lymphoma.

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More on DCIS

More, a magazine “for women of style & substance,” has an unusually thorough, now-available article by Nancy F. Smith in its September issue on A Breast Cancer You May Not Need to Treat.

Ductal Carcinoma in Situ (DCIS) in the breast, histopathology w/ hematoxylin & eosin stain, Wiki-Commons image

The article’s subject is DCIS (Ductal Carcinoma in Situ). This non-invasive, “Stage O” malignancy of the breast has shot up in reported incidence over the past two decades. It’s one of the so-called slow-growing tumors detected by mammography; a woman can have DCIS without a mass or invasive breast cancer.

While some people with this diagnosis choose to have surgery, radiation or hormonal treatments, others opt for a watchful waiting strategy. The article quotes several physicians, including oncologists, who consider the surveillance approach favorably and otherwise.

In 2009 the NCI sponsored a conference on diagnosis and management of DCIS. The participants issued a helpful, albeit technical, consensus statement.

The bottom line is that optimal treatment for DCIS remains uncertain because doctors don’t yet know the natural course of this early-stage breast malignancy. The ClinicalTrials.gov website lists active and ongoing studies.

 

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A Medical School Problem Based Learning (PBL) Parody of ‘The Office’

Last week a video came my way via ZDoggMD, a popular blog by doctors who are not me.

The Office Med School Edition

The clip is a parody of The Office about Problem Based Learning (PBL).

In a typical PBL, the students meet regularly in small groups. On Monday they begin with clinical aspects of a case. The process involves finding information and researching relevant topics to “solve” the diagnosis and /or a treatment dilemma. Over the course of each week the students move forward, working through a hypothetical patient’s history, physical exam and lab studies to the nitty-gritty of molecules, genes and cells implicated in a disease process.

It’s a lot of fun, usually.

The video was uploaded in February, 2007. It’s attributed to a group of med students at the University of Pittsburgh, class of 2009.

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The Immeasurable Value of Continuity of Care

Today I visited my internist for a checkup and flu shot. We talked about how I’m doing, and she examined me, and we discussed what procedures I ought have done and not done. She’s been my doctor since the summer of 1987, when I was an intern at the hospital.

We reviewed so much that has happened in the interim.

How rare it is, now, to have a doctor who knows me. Continuity in care is so valuable.

One of my greatest fears is being in the hospital again, and having hospitalists – doctors who work full-time in the hospital – be the ones to see me each day, and make decisions about what I need. Yet I’m bracing for it because, well, that’s how it is, now.

From a health care administration perspective, I recognize the value of delegating inpatient care to physicians who are not my usual doctors. And from the perspective of a physician who after hours and on weekends, would walk to and from the hospital, back and forth, countless times, to see my patients when they were sick, I know it’s neither cost-effective nor wise for physicians to push themselves to get over to the hospital before or after they’ve gone home, and called everyone back, and maybe eaten dinner. Doctors need rest, too.

But as a patient, when I’ve been in the hospital, nothing was more reassuring than visits by my usual doctors – my internist, my oncologist, my surgeon, my orthopedist…Being cared for by strangers, however competent, is not the same, although there may never be a study to prove it.

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1 in 70 Women Develops Breast Cancer Before Reaching 50 Years

A post in yesterday’s Well column, about coverage of breast cancer by the media, focused on the first-person narrative of NBC’s Andrea Mitchell. Journalist Tara Parker-Pope writes:

Her announcement has generated much discussion in the blogosphere, including an analysis by Gary Schwitzer, publisher of HealthNewsReview.org, who writes that Ms. Mitchell made some missteps in discussing her cancer.

The Times column goes on to consider what was said, and how it might have been said better, and I agree with much of it. But mainly it’s a meta discussion, journalists talking about how other journalists consider breast cancer facts, figures and narratives.

Buried deep is this number, that according to the NCI, one in 69, or for the sake of simplicity – approximately 1 in 70 – women in the U.S. will receive a diagnosis of BC in her forties. That is an astonishingly enormous proportion of women under 50 years affected by a devastating disease.

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‘The Big C’ is Failing

Watching the Big C feels like a chore lately.

It reminds me of the feeling I used to get when I had to see and examine a patient in the hospital, under my care for some administrative non-reason, who didn’t need to be in the hospital IMO,  and whose hospital presence took time my time away from patients who needed my attention. But because I was responsible, I’d go and see her every day just the same, and listen and examine, make notes and occasional suggestions.

The show is terrible. There, I said it on the Internet.

In the most recent episode, Cathy (the melanoma patient who’s said to be responding to a treatment about which viewers know nothing) runs into her oncologist at the pool where she symptom-freely coaches a swim team. The doctor, portrayed by Alan Alda, has a young wife who talks openly about sex with her husband and invites Cathy to a meal in their home.

So Cathy’s two for two for eating meals with her oncologists – one in each of the Big C’s seasons so far. Pretty much any cancer patient can tell you that’s highly unusual. Most people have trouble getting to see their doctors in the office for sufficient time, no less in their homes or in restaurants.

Second problem: the doctor’s wife speaks quite crudely about her husband’s talents in the bedroom. Really I wouldn’t care, except that as much as I’ve worked with and known some older male physicians and their wives, and seen some stuff, I’ve never, ever, heard a doctor’s wife, or a drunk doctor’s wife, or a doctor’s wife who’s drunk, speak so crudely about her husband’s sexual skills to a patient. I’m sure it’s happened, but not very often.

And if the show’s directors are so comfortable covering sex, and tampons (last episode), and urine (pee in the pool, did they really have to include that?) and death (there’s a bit of a morbid thread emerging), they could talk about THE BIG C, i.e. Cathy’s melanoma.

If you cover all of the above, why not some jaundice, emesis (med-speak for throwing up), leukopenia (low white cells) or fatigue, or something having to do with cancer, treatments and side effects, or informed decision-making?

This program is a lost opportunity to, in a light-hearted and well-acted way, help people (1) understand what it’s like to go on a clinical trial, (2) live with advanced cancer, and (3) deal with a family during cancer treatments. It’s struck out.

(first sports metaphor on ML; probably the last -)

I’ll follow until the end of the season. Maybe it’ll turn around, but I doubt it.

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End of Summer Blog-Break

Dear Readers,
ML will take a blogging break through Labor Day. I hope the storm doesn’t cause too much damage.

Stay safe, wherever you are, and enjoy these end-of-summer days!

– ES

waves (stock photo)

—-

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Considering Steve Jobs, Medical Diagnoses and Privacy

Yesterday morning I wrote a short post on CelebrityDiagnosis.com. By evening, news broke that Apple founder and CEO Steve Jobs resigned from his position, presumably for reasons of his health.

What’s public, by Jobs’ decision, is that he had a relatively good, typically slow-growing kind of malignancy in the pancreas, a neuroendocrine islet cell tumor. He informed Apple employees by email about his diagnosis in 2004, when he was 49 years old. Since then he’s had a liver transplant. Possible complications of that surgery, or the tumor itself, have led to considerable speculation. But little is known about the details of why he took medical leave in January and is stepping down now.

In a published letter to the Apple Board and Community, he wrote yesterday: “I have always said if there ever came a day when I could no longer meet my duties and expectations as Apple’s C.E.O., I would be the first to let you know. Unfortunately, that day has come.”

The letter was “short and classy,” in David Pogue’s words, and I agree. I respect Jobs’ decision to keep the details of his medical condition private. That’s the thing – and where this is post is heading.

When public figures are open about their illnesses, it can be helpful, instructive and even necessary. For example, if a political figure, say Fidel Castro or Hugo Chavez or Dick Cheney, with considerable power develops a cancer or has a stroke or a heart attack or some other serious medical problem, the citizens have the right to know that the condition of the person they rely on has changed.

Sometimes it’s instructive to learn about famous people’s medical stories, as is illustrated in Barron Lerner’s book, When Illness Goes Public: Celebrity Patients and How We Look at Medicine. Openness about breast cancer by women like Happy Rockefeller, Rose Kushner and more recently Elizabeth Edwards (to name a few among many) have helped women move forward, from being ashamed of having BC to understanding about what it’s like to live with the disease. They helped other women to understand this disease, through their generosity of personal stories and experience.

The problem is that in our culture there’s so much openness about medical conditions, individuals may feel compelled to tell what’s happening if they have cancer or a recurrence or some other unfortunate medical event. But not everyone wants to do so, nor should they feel obliged.

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