End of the Big C Season 2, ML Coverage Stops

Last night Showtime aired the second season’s finale of the Big C. As usual, there was no detail whatsoever about Cathy’s advanced melanoma or treatment.

I didn’t think the show could get worse, in the reality-of-having-cancer sense, but it did. Cathy, who still looks great and complains of no physical problems, determinately runs, walks and trudges through a New Year’s marathon. OK, that might happen, but it shouldn’t.

Biggest mistake ever in this series so far: In a scene near the end, Cathy’s first oncologist shows up at the race to see her meet the finish line. While they’re waiting, he and Cathy’s teenage son Adam go to a diner. Adam asks the doctor about his mom’s prognosis, and the oncologist answers.

It’s a blatant, medical ethics 101 no-no – talking to a patient’s family member without her permission. And to a minor, no less.

I just read the program has been renewed for a 3rd Season. I may check in occasionally, just to see if it improves, but I’m not going to watch regularly. Unlikely I’ll write on it again, unless the Big C gets real about melanoma and Cathy’s life with illness.

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By |September 28th, 2011|Reviews, TV|0 Comments|

‘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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Medical Aspects of ‘The Help’: The Plight of a Woman with Recurrent Miscarriages

the character Celia, in "The Help"

Last weekend I saw The Help, a movie on race relations in Jackson, Mississippi 50 years ago with lingering implications for people who hire “help” to take care of their children and tend to their personal business anywhere in the world, including now. It’s a heavy-handed, simple-message and nonetheless very enjoyable film, with fine acting and imagery, based on the book of the same title by Katherine Stockett.

One element of the narrative interested me from the medical perspective, having to do with the plight of a pale, thin and sexy young woman who’s marginalized by the white Jackson social elite. The character Celia, portrayed with flair by Jessica Chastain, lives, isolated, on an out-of-town plantation. She spends her days alone while her husband’s at work. The nominally proper women in town, while playing bridge and otherwise gathering, call her “white trash,” and she sometimes lives up to their prejudices by drinking too much and behaving erratically.

It turns out the young woman’s having a hard time because she’s unable to bear children. She feels inadequate and fears her husband might leave her if he found out. Her history of recurrent miscarriages is discovered by the African American maid, Minny, who comes to work with her. In a revealing scene Minny finds Celia locked in the bathroom, severely bleeding from a miscarriage and crying. The maid, played with conviction by Octavia Spencer, helps her to recover, clean up, and bury the fetus in a shoebox in the yard, nearby three other small burial sites. With this, the young woman’s odd behavior becomes comprehensible.

I couldn’t help but think of countless women of earlier eras, and friends I’ve known in my adulthood, and women I’ve treated as a physician, who felt really bad about their inability to bear children. These days, with fertility treatments and work-ups for miscarriages so prevalent in communities like mine, we don’t see so many cases like Celia’s. It used to be a common problem, and it still is in many regions in the U.S and certainly in other parts of the world, for women who have difficulty conceiving or carrying babies to term, not just to not have children, but to become sad, and feel inadequate about themselves as women.

The Help is a worthwhile film at many levels, with fine acting, a good, PC message and story. I hope movie-goers will take special note of Celia’s predicament.

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On Reducing Cancer Care Costs by Resetting Expectations, and Hope

Today we should move forward on the list published in the NEJM on Bending the Cost Curve in Cancer Care. We’re up to point 7 in our discussion, what’s 2nd in the authors’ proposed changes in attitudes and practice: “Both doctors and patients need to have more realistic expectations.”

This point follows closely from the previous, that doctors need to talk with patients earlier on end-of-life issues. But the central issue here is that most patients with cancer are unrealistic about their prognosis, and that oncologists do a terrible job in correcting their misperceptions:

…According to one recent study, most of the patients with lung cancer expected to live for more than 2 years even though the average length of survival is about 8 months.3

Resetting expectations will be difficult. Tools are available to help the oncologist provide truly informed consent by sharing anticipated response rates, chances of cure (always near zero for patients with metastatic solid tumors), and side effects…Many oncologists do not have these skills,43 so use of a decision aid may help…

What they’re describing amounts to Lake Wobegon effect, from the patient’s perspective, and that may be fair enough.

But I think these authors are letting oncologists off easy. Why it is that they lack “these skills,” i.e. what it takes to help patients face reality? It happens yesterday I was reading Dave deBronkart’s book, How to Laugh, Sing and Eat Like a Pig, on his experiences as a patient with metastatic kidney cancer, and he cites a terrific, pertinent excerpt in Dr. Jerome Groopman’s The Anatomy of Hope:

Hope, unlike optimism, is rooted in unalloyed reality. …Hope acknowledges the significant obstacles and deep pitfalls along the path. True hope has no room for delusion.

Clear-eyed, hope gives us the courage to confront our circumstances and the capacity to surmount them. For all my patients, hope, true hope, has proved as important as any medication.

Groopman’s point is that real hope rests in reality.

Going back to the NEJM piece –

I don’t think oncologists need (or better, should need) decision aids to help them reset patients’ unrealistic expectations. What they need is time, and thoughtfulness, and the capacity to be genuinely empathic.

If our health care system promoted trusting, and ideally longer, relationships of cancer patients with their physicians, patients would be less fearful of hearing the truth, and their doctors would be less afraid to speak honestly with them. This would reduce cancer care costs by lessening futile treatments, and would improve the quality of the patient-doctor relationships in oncology, besides the quality of care, in itself, and patients’ experiences as they near the end of life.

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Cathy Swims and Runs in Episode 6, Season 2 of the Big C

I almost liked the latest installment of the Big C. Cathy swims, for starters. I could relate.

She’s wearing goggles, no less. That’s universal “code” for seriousness about swimming, or acting. She swims well and pretty fast. Within seconds she befriends the competitive girl-swimmer in the next lane and, wouldn’t you know it, the girl’s team needs a new coach.

Cathy, who is undergoing treatment for Stage IV melanoma in a clinical trial about which the audience knows 0, steps in to coach the team. She meets some resistance from parents who worry about her condition and associated unreliability. She alludes, vaguely, to her rights as a cancer patient and firmly vows to lead the team.

“I can do it” is this episode’s message.

After some ups and downs, and after the viewer suffers from the director’s crude decision to mix the patient’s possibly having a pelvic rash as a side effect with her learning that she has crabs, aka pubic lice, Cathy goes running with the swim team members.

Cathy runs with the team in Showtime's 'The Big C'

How often can a metastatic cancer patient in the midst of serious systemic (meaning non-surgical, not focused radiation or minor) and non-hormonal cancer treatment run with athletes 25 years younger? Only on TV, or in very, very exceptional cases.

Some basics, please: How about feeling tired? Or a relevant rash?

A dose of reality might help this TV program that’s said to be about cancer, or life with cancer.

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Live Every Week Like It’s Shark Week, Again!

Tonight the Discovery Channel will begin its annual Shark Week festival on TV. “Show me your teeth,” dares a singing woman, repeatedly, in the preview.

Show Me Your Teeth

I’m reminded of my thoughts on the advice – if you can call it that; it holds as a puzzle with me – from the recently-troubled Tracy Morgan as Tracy Jordan on NBC’s 30 Rock. Here’s a rerun, from last year’s ML on the same:

Dialog from Jack the Writer (Season 1, Episode 4, 2006):

Tracy Jordan: But I want you to know some­thing… You and me, it’s not gonna be a one-way street. Cos I don’t believe in one-way streets. Not between people, and not while I’m driving.

Kenneth: Oh, okay.

Tracy Jordan: So here’s some advice I wish I would have got when I was your age… Live every week, like it’s shark week.

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Now, five years later, I still don’t watch the Discovery Channel by choice. And I’m afraid of sharks when I’m in the water in places where they might be near. Last season, I watched 30 Rock less regularly than before, not just because of Tracy’s frequent absence, but  mainly for lack of time. Still, what I enjoy most on that show is watching Alec Baldwin, who continues to set a fabulous example of how a talented and handsome man can pick himself up after a rough patch.

Just yesterday I was swimming in the pool next to people in scuba gear practicing for the real deal. I wondered if they watch Shark Week, or live by it, somehow.

How have Tracy’s words influenced me?

Well, I’m determined to get my book done, to take care of my mind and body, and to enjoy part of every single day. No deep insight, really. But true, at least for today. Maybe next year, I’ll have a more interesting thought on the subject of Shark Week. I might even watch the program.

Now, back to the real thing (what matters now: my book, my health, my family).

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Thoughts on the Death of Amy Winehouse

I feel compelled to write at least a short note on Amy Winehouse, a young woman who was found dead in her London apartment a few days ago. I don’t like to speak ill of the dead, but the truth is I was never a big fan of her music. I wasn’t fond of her highly-stylized hair or her weirdly-curved eyebrows.

Once, when I was 17, a friend told me he always tries to see the good in people, no matter how much they behaved disagreeably. Ever since he said that, it’s stuck. Today his words come through, in contemplating Amy Winehouse’s personality and short life.

I like her for her willfulness, even though it was so destructive.

Amy Winehouse, in 'Rehab' Video

Not a good medical lesson, for sure – or the message most people are telling their kids upon this “teaching moment,” but not everything I care for is just how it should be.

Yes, she should have gotten more help for her addictions. She needed it, that’s obvious. Family and friends, take note!… You can intervene and make a difference in a troubled person’s life.

But sometimes this happens in medicine, when you’re caring for a patient who smokes or drinks or smokes and drinks or does something else unhealthy, or in a family, or among friends – it’s not always so helpful to simply criticize and judge or lecture and point the person to the door.

So here’s another take: to identify something good in the person, and focus on that, and remember that.

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The Big C: Cathy Goes For Treatment

In this week’s episode, Boo!, Cathy wakes up in the morning eager and ready to start treatment on a clinical trial. The day doesn’t go well – the local treatment center doesn’t have needed information about her insurance, which can’t be tracked down on time, her 15 year old son gets in trouble at school, and her husband loses his job.

That kind of day – when it seems like everything possible that can go wrong, goes wrong – will seem familiar to many if not all cancer patients. 

But the show continues to fail in providing any meaningful cancer information whatsoever. OK, I’m starting to accept the fact that ratings would suffer if the doctor gave even a 30 second mini-talk on BRAF mutations in melanoma. There will be no science on Showtime. But the scriptwriters could, at least, have included the discussion of the doctor and Cathy’s signing informed consent for the trial. There’s not a word about what treatment she’s getting, or what the shots she took in the last episode were for.

You’ve got to wonder if Laura Linney’s character, the “patient,” understands the purpose of the trial she’s on, the nature of the experimental treatment and risks.  The FDA approved Yervoy (ipilimumab) for patients with advanced melanoma months ago (considered here). Did her oncologist offer her that drug and, if so, why did she choose the clinical trial? Might the oncologist have a conflict of interest, in regard to the research? Is Cathy enrolled in a Phase I, II or III trial?

Please tell me something about her treatment! So far I see the Big C as a lost opportunity for teaching about cancer medicine – through humor and the potential talent of a terrific actress, or about meaningful and realistic patient-doctor relationships, or about informed consent.

If I hadn’t said I would follow the show and post on it this season, I’m not sure I’d bother watching it any further.

But I’m a compulsive sort of doctor-blogger-patient: I’ll keep watching it, at least for this year’s episodes, and I’ll keep you posted, in case you care about Cathy’s predicament, or if you want to share her thoughts on the show.

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Cathy Wants a New Doctor and a Second Opinion

Last night the Big C returned, not surprisingly with an opening dream sequence. Laura Linney, portraying Cathy Jamison in the Showtime series, is running. The scene turns out to be a nightmare, and she awakens with a headache and her husband by her side.

Laura Linney portrays Cathy, hugging her son in Showtime's "The Big C"

OK so far.

Within a few minutes, Cathy’s young oncologist informs her that the interleukin 2 hasn’t worked; after two rounds of “chemo” the melanoma hasn’t budged. Sitting at his desk in the consultation room, he suggests she roll some joints for relief of headaches. She says she wants another opinion. It’s about time.

The main problem Cathy faces in this episode is that she can’t get an appointment with her oncologist of choice, Dr. Atticus Sherman despite calling, calling and calling. So finally she thinks out of the box: “That would be a coffin,” intimates her deceased, elderly neighbor Marlene who visits, spiritually, from Season 1.

So Cathy dons a suit and heels, and pulls a small suitcase with wheels – in the style of a drug sales rep – to work her way into the famed oncologist’s office. This desperate strategy, reminiscent of that suggested by journalist Elizabeth Cohen in the Empowered Patient book, and tried at least once by Samantha in Sex in the City when she had breast cancer, seven years ago or so on HBO, nearly backfires. But in a stroke of changed fate, the same doctor’s office calls Cathy to let her know she’s got an appointment for next week.

Such drama, just to get an appointment didn’t move me. But perhaps I’m too removed from this sort of painfully real situation for the countless, frustrated patients who can’t get appointments with appropriate specialists.

I was disappointed with the episode for other reasons. It wasn’t rich with ideas. There was no meaningful discussion of Cathy’s cancer, and only a shallow exploration of her feelings.

Like other TV comedies, this show was about everyday junk and family life: her son’s farting habit, her friend’s active sex life and pregnancy, her brother’s insanity, her dog’s seeming to be dead and then turning out to be alive. This (non) focus is fair enough, I suppose; when a person has cancer, they’re indeed surrounded by people in their family and friends who have their own needs and issues.

A particular beef is this: Clearly Cathy needed a second opinion; that’s been the case all along. But the script-writers made it too easy by having the young oncologist be utterly clueless and behaving inappropriately. The value of a second opinion would be clarified if Cathy had chosen to seek another doctor’s input even if she were receiving seemingly expert care from a solid, more experienced physician.

And where is the Internet in all of this? Her friend Rebecca (Cynthia Nixon) might be looking some stuff up. Or her brother, for that matter, who’s now said to be manic depressive, could be maxing out on free and potentially useful information. His anger at his sister would be more credible if it were less extreme and if he were less bizarre; his is not a fair or typical depiction of his stated mental illness.

How will Cathy’s appointment with Dr. Sherman go next week? We’ll see.

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Gregg Allman Stars in Hepatitis C Awareness Campaign, with Merck

This weekend I learned that Gregg Allman, of the Allman Brothers, has hepatitis C. Not just that; he underwent a liver transplant last year for treatment of liver cancer. This information came my way via CNN, in a clip narrated by Dr. Sanjay Gupta. The cable TV crew filmed the old rocker in Macon, Georgia, at the band’s Big House.

Gregg Allman, performing in 2010 (Wikimedia Commons)

“He’s taping a public service announcement for the drug company Merck, about hepatitis C,” Gupta says 40 seconds or so into the clip (italics added, ES).

Hepatitis C stays silent in many carriers, meaning that most people with the virus are unaware of their infected state. The liver-infecting virus spreads most often by contaminated needles, sexual relations or transfusion of infected blood. Over time, the virus tends to cause liver damage and blood problems including anemia and, rarely, a condition called mixed cryoglobulinemia. In patients with long-standing hepatitis C, there’s a significantly elevated risk of developing liver cancer.

For two decades there have been a few, fairly effective anti-viral drugs available for hepatitis C. Treatment generally reduces patients’ anemia and liver disease, which leads them to feel better, and also reduces the risk of the long-term effects of infection, including liver cancer. Last month the FDA approved two new drugs for hep C: Victrelis (boceprevir), manufactured by Merck, and Incivek (telaprevir), by Vertex Pharmaceuticals.

While I have no formed opinion as to which of these new drugs is most effective or less toxic or more affordable in the long term for patients with hepatitis C, I do find it strange that Gregg Allman will be singing for Merck.

Eat a Peach (album cover)

The ethics of this are complicated: On the one hand, it might be a good thing for a music icon to raise public awareness about hepatitis C, so that more people at risk might get tested and then treated early before they develop severe liver disease and cancer, and would feel better. Gregg Allman is in a position to spread that message effectively: “If I have hep C, you might have hep C. Let me tell you about it…” (somewhat in the style of Magic Johnson, on HIV).

On the other hand, the notion of a post-transplant musician serving as the public’s primary source for information on hepatitis C seems preposterous, especially if he’s tied in with a pharmaceutical company with a stake in the matter. The situation is reminiscent of Sally Fields starring in commercials for Boniva, an osteoporosis drug.

You might ask yourself – and it’s not a trivial exercise – who can best, and objectively, inform the public about viral liver infections and the potential benefits of treatment: doctors? (we harbor biases; many have industry ties); patient peers? (Allman is a heightened example, but he’s hardly objective about this, either); newspapers? (or radio…

Will Allman’s be wasted words? (Hard to resist.) Really I’m not sure.

But I might go to Allman’s concert for the American Liver Foundation, at the Beacon Theater, scheduled for July 27.

All for now.

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Looking Back on ‘The Normal Heart,’ and Patients’ Activisim

A few weeks ago I saw The Normal Heart, a play about the early, unfolding AIDS epidemic in NYC and founding of the Gay Men’s Health Crisis. The semi-autobiographical and now essentially historical work by Larry Kramer first opened at the Public Theater in 1985.

Cover of the paperback, published by “Plume,” from Wikipedia

The story takes on the perspective of a young man who’s seeing the death of too many of his friends and neighbors from a strange and previously-unknown disease. As much as the situation is disturbing, and frightening, and shattering of the gay men’s barely decade-old freedom to behave as they choose, most of the protagonist’s associates just can’t deal with it. Nor can other, potentially sympathetic officials like Mayor Koch, health officials at the CDC and NIH.

Among the men who form GMHC, in this drama, there’s a mixed crew. Some say they’re  embarrassed by the attention the illness drew to some gay men’s behavior. Many stay fully or half-closeted, understandably insecure in their jobs. They worry about discrimination and rejection by families, landlords and even doctors, some who were reluctant to take on patients with this disease. Some of the affected men and their friends, straightforwardly, fear death; others are in plain denial about what’s going on in their community.

The scenes unfold between 1981 and 1984, more or less the time when I moved to Manhattan, lived downtown, applied and matriculated at NYU’s medical school. Many of the first clinical cases, i.e. patients, I saw, were young men with HIV and Kaposi’s sarcoma, one of the first conditions associated with the outbreak and that’s featured in the play – the appearance of maroon or violet-colored, usually but not always flat, often elongate, spots on the skin. The AIDS patients tended to have anemia, either from immune blood disorders or, more often, infection in the bone marrow. As a hematologist-to-be, I was intrigued.

Then and now, looking back, it’s hard not to respect those men’s activism, especially those who, with Kramer, created the AIDS Coalition to Unleash Power (ACT UP). They were impatient with the pace of research and physicians’ protocols, and spoke out so emphatically about their needs: for more research; for prevention and treatment; for easier access to new drugs; and, simply, for good medical care.

The play closes soon in New York;  its producers are said to be planning a tour and a London production of the work. Patients and their advocates, of all backgrounds and particular concerns, might take notes.

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What’s Next on the Big C? (Hopefully a Second Opinion)

(Hopefully a second opinion)

When I last wrote on The Big C, a Showtime series in which the actress Laura Linney portrays a woman in her forties with advanced melanoma, I considered some of the options she might choose when the series resumes next Monday night.

Laura Linney, in Showtime's 'Big C'

At the end of Season 1, she elected to try a course of IL-2 as was recommended by her young oncologist. Meanwhile, the FDA has approved Ipilimumab (Yervoy), an antibody treatment that revs up the immune system. And she’s in line, according to the script, for possible entry into a clinical trial that likely involves a targeted therapy, like vemu­rafenib for patients whose malignant cells have a genetic mutation in B-RAF.

What I expect Cathy will do, before anything else happens and she receives any additional non-urgent treatment for her advanced melanoma, is get a second opinion. She’s a smart, sensible sort; in retrospect it’s hard to believe she didn’t do this earlier on and before starting the IL-2 therapy.

I wonder, also, if one of her family members or friends will do some research about melanoma on the Internet. That would help her find a doctor with appropriate expertise, and better know what questions she should ask of the oncologist during the consultation.

That’s all on Cathy’s decision, until next week.

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Faking the News (and Informational Chaos)

Logo for Frontline, a PBS program

I read in the paper this morning that some hackers successfully (?) broke into the PBS website on Saturday night and posted a story that is untrue. According to multiple sources, the fabricated article stated that Tupac Shakur, a rap performer who died in 1996, is alive and living in New Zealand.

Fox “News” (quotations added by ES) reports a group claiming responsibility was annoyed by a recent Frontline show on WikiLeaks. I googled Tupac and readily identified what is said to be his official website, 2pac.com. There’s a page dated sometime in February 2011, on the Legend:

…Born on June 16 1971 in New York City, Shakur’s parents were both members of the Black Panther Party whose militant style and provocative ideologies for civil rights would come to influence 2Pac’s music. At an early age, Tuapc’s love for performance and the arts began to show, as he began acting at age 13 and later enrolled in the Baltimore School of the Arts before dropping out at 17. Shakur broke into the music business with rap group Digital Underground as a back-up dancer and roadie. Eventually Shakur released his first solo album in ’91, 2pacalypse Now. 2Pac’s music career began to grow as his second album, Strictly 4 My N.I.G.G.A.Z included 2 top 20 pop chart tracks: I Get Around and Keep Ya Head Up.

Shakur’s legal battles began after he established his rap career. In the early nineties Shakur faced a wrongful death suit which settled out of court, accusations of assaulting police officers where charges were ultimately dropped, and even an incident where Shakur sustained 5 gunshot wounds from unknown assailants. In 1995 2Pac was sentenced one-and-a-half to four-and-a-half years in prison for sexual abuse. However, not even prison could slow the success of Shakur’s career.

While incarcerated 2Pac’s latest album, Me Against the World, was number one in the pop charts and would later go double platinum. Shakur became the first artist to reach number one in the pop charts while serving a prison sentence. Making the most of his time in jail, 2Pac became a passionate reader. Among his favourites were the works of Niccolò Machiavelli, an Italian Renaissance writer whose works were in part the foundation for western political science. Shakur’s appreciation of his work inspired the nickname: Makaveli.

After serving only eight months of his sentence, 2Pac was out on parole thanks to a 1.4 million dollar bond paid by Suge Knight, CEO of Death Row Records. Now signed with Death Row Records, Shakur went on to create All Eyez on Me, which featured hits How Do You Want It and California Love.

2Pac’s life was cut short in September of 1996 when Shakur became the victim of a drive-by shooting while his car waited on a red light. While Shakur survived the surgery that followed he was pronounced dead almost a week after the attack.

Even today, 2Pac’s influence is wide-spread…

album cover, "all eyes on me"

I have no idea how much of the legend is true, or if the 2pac website is really sponsored by the Tupac Amaru Shakur Foundation. Based on my limited education, I can confirm that Niccolò Machiavelli was an Italian philosopher of the Renaissance period whose writings influence some political scientists today. I might also confirm that guns really do kill people, here and elsewhere. This statement is based on my general knowledge and life experiences as a physician and citizen of the U.S.

In addition, I now know with certainty that at least one of my sons is familiar with Tupac’s music. He identified the artist in passing, while he walked by as it streamed from my laptop. He wondered why I was listening. In truth, I’m not sure about this. Curiosity, I suppose –

You can find some Tupac songs on YouTube. Based on a limited, first-time review this morning, I’d half-recommend Keep Ya Head Up. (You can send a ringtone to your cell phone, through this website with the lyrics.) In another video, he performs a song called Makaveli the Don. You can buy his CDs at Amazon.com, or elsewhere, or read one of several biographies.

My conclusion: It’s an information jungle out there.

The Medical Lesson: It’s hard to know your sources, especially when hackers can pretend to be a public broadcasting service. The only protection, as with health info that might come from a journal or doctor or a textbook in Texas, is having a good education and breadth of knowledge with which to assess the credibility of whatever you read or hear.

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Good People, a New Play About Chance, Decisions and Fate

A short note on Good People, the title of a new play at the Manhattan Theatre Club starring Frances McDormand

It’s a simple story, at some level, about a middle-aged woman from south Boston who loses her job. She has a disabled, adult daughter who needs caregiving, and she needs money. She contacts some old friends, and scours the neighborhood for a job. She encounters a once-boyfriend, just for a summer at the end of her childhood, who’s become a doctor with a fancy office and a fancy house and a beautiful wife.

Frances McDorman, in a photo for the MTC

And she’s angry, angry because she’s never been able to leave her community despite, as she puts it, “being nice.” She put her daughter’s needs first and helped others when she could – or so she says, but she was too often late for work at one job and the next, because she was waiting for the daughter’s sitter, or because she couldn’t pay the bill on her car, or for some reason or other unfortunate event, as she sees it, that isn’t quite her fault.

The play’s well-executed, with firm acting and revealing details – like the wallpaper and mismatched furnishings  in the woman’s kitchen, and the spotty sportswear the women don when they go out to be sociable. Some scenes take place in a church, where the characters chat as they play “BINGO,” waiting and hoping for a lucky break.

It’s about fate, and responsibility, and assumptions people sometimes make. And it’s closing this Sunday.

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First Look at the Burns Collection of Early Medical Photographs

CBS News has posted a gripping set of images, mostly of cancer patients, dating to the 1880s. The photos from the Burns Archive are graphic, as much as they’re telling, instructive and rare.

 

This photograph, taken in New York City in 1886, is one of the earliest ever taken of breast surgery. Surgeons had begun to adopt infection-control measures in the operating room, but at this point they hadn’t yet adopted the use of surgical masks and hats and their surgical gowns were simply put on over their street clothes. The anesthesiologist whose hands are visible holding the patient’s arm on the left side of the frame is wearing street clothes. Anesthesiologists were the last doctors to don surgical clothing in the operating room.

Credit: Dr. Stanley B. Burns, via CBS News

According to its website, the Burns Archive houses the nation’s largest and most comprehensive collection of early medical photography (1840-1920). It turns out the collection is based on East 38th Street. It’s nearby, and I should explore it for real.

Meanwhile, I recommend that my non-squeamish readers take a look at the CBS-published images. If nothing else, these digitized relics display how far improved are surgical methods – and cancer treatments – since the late 19th Century.

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Interleukin 2, Cathy’s Planned Treatment in the Big C

I’ve been toying with the idea of messing with a cable TV show’s plotline. At the first season’s end of The Big C, the story’s protagonist decides to accept a harsh and usually ineffective treatment for her advanced melanoma: interleukin-2 (IL-2).

Laura Linney as Cathy (Showtime image, The Big C)

Cathy, played by the actress Laura Linney, understands the goal is not for a cure, but to temporize her disease for six months, when she might be eligible for a new melanoma drug through a clinical trial. Her oncologist has already completed the paperwork, according to the old script. The season ends with Cathy in a hospital bed with an IV catheter, presumably receiving the IL-2, and dreaming.

So I thought I’d explain a bit on interleukins and IL-2 in particular:

Interleukins are proteins defined by their capacity to communicate between different populations of white blood cells (between leukocytes). The term was put forth by a group of scientists who studied lymphocyte activation in a 1979 paper in the Journal of Immunology. IL-1 was the first named interleukin, IL-2 was the second, and so forth.

IL-2 was first known as Lymphocyte Activating Factor (LAF). It went by other names, too, including Helper Peak, T-Cell Replacing Factor III, and B-Cell Activating Factor (BAF). It’s a powerful cytokine, a molecule that stimulates other cells to grow and mature. Most of it comes from T-cells. For decades, doctors have been aware of IL-2’s anti-tumor potential: it can stimulate the body’s natural killer, lymphokine-activated killer (LAK) and other cytotoxic cells to destroy malignant cells.

Now, human IL-2 is available in recombinant form. This means that researchers don’t need to purify the stuff from growing cells. Instead, companies use its genetic sequence to manufacture the protein in commercial labs, much in the way that other hormones are synthesized for medicinal use – like insulin or growth hormone. Recombinant human IL-2 is called Aldesleukin and sold as Proleukin.

When I was a resident and a fellow, I gave IL-2 to some cancer patients and monitored their reactions in clinical trials. It’s not an easy drug to take, as is emphasized in The Big C, set to resume on TV June 27.

This year, on March 25, the U.S. FDA approved an antibody treatment for advanced melanoma: Ipilimumab (considered here), now sold as Yervoy. Just yesterday, as considered in the Pharma Strategy blog (with a helpful chart of BRAF inhibitors), Roche/Genentech submitted an application to the FDA for approval of an experimental agent, vemurafenib (aka PLX4032), for treatment of patients with advanced melanoma.

What will Cathy do? I have no idea. But it’s good to know her treatment options are broadening.

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E-Patient Dave Explains What It Means to Be An E-Patient

Med-blog grand rounds this week is hosted by e-patient Dave, who is Dave deBronkart, a real man who was diagnosed with a renal cell (kidney) cancer a few years back. He’s a terrific speaker and an Internet friend.

By coincidence I was searching for the definition of an e-patient, and came upon it there, in a video of his presentation at the TED (for those of you in the 1990s, that would be Technology, Entertainment, Design ideas worth spreading) “x” – meaning independently-organized meeting held in Maastricht a few weeks ago. Dave and others spoke on the topic of “The Year of Patients Rising.”

Dave explains: An e-patient is empowered, engaged, equipped and enabled. Got it?

e-patient Dave, in Maastricht

In Dave’s bio, he attributes the “e-patient” term to the late Dr. Tom Ferguson, a physician and author who, with Dave and others, founded the Society for Participatory Medicine.

All for today –

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Until Tuesday, A New Book About a Very Strong Person

A short note on a book party, fundraiser and warm celebration I attended yesterday evening. My first Facebook friend, Luis Carlos Montalván, an acquaintance from my experience at Columbia’s Journalism School, has published a wonderful book, Until Tuesday (Disney-Hyperion).

I received a copy of the book at the gallery, and couldn’t put it down. Luis, a seasoned veteran and former Captain in the U.S. Army, earned the Combat Action Badge, two Bronze Stars and a Purple Heart medal. He was severely injured during his deployment in Iraq, and came back with deep emotional and physical wounds.

His wonderful book is a tale of healing, aided by a special dog, but really it’s about human healing, and Luis’s determination to get well.

I am inspired by Luis, first that he got his book out (he beat me to it!), and also for being so brave in telling his story. It’s not an easy one, but it’s intense and will forever influence how I think about soldiers.

“Some people in the room know that every day 17 veterans commit suicide,” he mentioned to the group. I wasn’t aware, until yesterday.

For those of you who missed the party last night, you can check out this clip from CNN this morning, but of course it’s not the same as meeting Tuesday in person.

Thanks Luis, for being so forthcoming, and strong!

—–

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Change the Channel?

The situation in Japan remains grim. I can’t reasonably report on this, except to say what’s evident by the photographs, videos and usually-reliable sources: a second reactor may have ruptured. There’s been another burst of radioactivity into the air.

Flickr, Official U.S. Air Force photo stream

Meanwhile, thousands of bodies are being discovered in the post-Tsunami landscape along the northeast coast. The Emperor’s speech adds a feeling of gravity, essentially unfathomable to those who are not there, and maybe even to those who didn’t live, first, through the atomic bombings in that country 75 years ago.

people in a shelter, as shown on NHK world TV

Working my/our way* through The Pain of Others, Sontag writes:

What to do with such knowledge as photographs bring of faraway suffering? …For all the voyeuristic lure – and the possible satisfaction of knowing, This is not happening to me, I’m not ill, I’m not dying, I’m not trapped in a war – it seems normal for people to fend off thinking about the ordeals of others…

People can turn off not just because a steady diet of images of violence has made them indifferent but because they are afraid…

She considers the role of TV, and the CNN effect regarding images from the war in Sarajevo, and says now (in the book):

The question turns on a view of the principal medium of the news, television…Images shown on television are by definition images of which, sooner or later, one tires. What looks like callousness has its origin in the instability of attention that television is organized to arouse and to satiate…The whole point of television is that one can switch channels, that it is normal to switch channels….

*in reality, her book-essay – on war imagery – grips with relevance, I sped through.

Probably by now, my dear readers are wishing I’d write on something else, and somewhere else, which indeed I am doing with most of my time now. But I think the real-time contemplation of the images – and why we look at them, or don’t – is valuable in itself.

And also, maybe it would help the people of Japan, there, to know that people are thinking about their plight.

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Live-Blogging a Book, and the Earthquake

I don’t know if makes sense to blog on a book by a woman who’s dead, who wrote about photographs and the news. But new media allows us to try new things, unedited. Here goes:

In Regarding the Pain of Others, which I began, unknowingly, on the evening before the recent quake and tsunami, Sontag begins Chapter 2:

Being a spectator of calamities taking place in another country is a quintessential modern experience <she refers mainly to war photography>…’If it bleeds, it leads’ runs the venerable guideline of tabloids and twenty-four-hour headline news shows – to which the response is compassion, or indignation, or titillation, or approval, as each misery heaves into view.

This observation, published in 2003, would account for CNN’s sending so much of its lead staff – Anderson Cooper, Dr. Sanjay Gupta, Soledad O’Brien and others – to northeastern Japan now. Some of us are drawn to the images of devastation, and these do sell.

(AP Photo/Asahi Shimbun, Toshiyuki Tsunenari)

The author continues, later:

…But there is shame as well as shock at looking at the close-up of a real horror. Perhaps the only people with the right to look at images of suffering of this extreme order are those who could do something about it – say, the surgeons at the military hospital…or those who could learn from it. The rest of us are voyeurs, whether or not we mean to be…

So maybe (as she sees it, in Chapter 2) it’s OK to look at the images if there’s a good reason to do so – for examining how others cope with a catastrophe by distributing food in limited amounts in orderly lines in order to learn, for example; or for demonstrating which structures withstood the quake and flood, which breezed over the seawall; or for planning the location and cooling protocols for nuclear reactors elsewhere…Also, quite plainly, the images may serve to raise money and needed support for the devastated region.

A soldier carries an elderly man on his back to a shelter in Natori city, Miyagi prefecture on March 12, 2011. (Photo credit: STR/AFP/Getty Images, via Flickr, as permitted)

Back to medicine – today, people are quite familiar with images of sick people. There are open, on-line communities of people sharing heartache and complications, sometimes with wrenching images. TV and the movies familiarize us with catastrophes to such a degree they may seem ordinary or unimportant. We’re desensitized, I fear, in which case the news audience’s attention is strangely reassuring.

"Japan Earthquake: Watching the Terrible News on TV" (flickr by LuisJouJR)

Maybe the people who are looking at the pictures are doing so because they really care about the people in northeast Japan. Or maybe it’s because they’re wondering – could this happen to me, all of a sudden, in the middle of an ordinary day, i.e. do I need to worry about this? Or both.

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