A Little Bit of Good? on Dying, Communication, and Breaking Bad

Within the realm of narrative medicine on TV, Breaking Bad took us to a dark and violent place. The devastatingly brutal finale took the protagonist, Walter White – a cancer patient and chemist like no other – where he was destined to go from the start: he died. Walt had, from the first episode, a diagnosis of inoperable lung cancer. And he was human. So there’s no surprise, really.

What made the ending so memorable, besides wrenching, was Walt’s final surrender, to his circumstances. He accepted his impending death and decided, with what hours remained, to do some good. It wasn’t much, but he tracked down former friends and directed them, however forcibly, to provide for his son; he spoke honestly with his wife; he took a bullet.

a scene from the last episode, 'Breaking Bad' on AMC

a scene from the last episode, ‘Breaking Bad’ on AMC

Walt, a school teacher, got turned on to cooking crystal blue methamphetamine. He, a man who in the beginning could barely hold a pistol, became a ruthless killer. He called himself Heisenberg, after the physicist who established a principle of uncertainty. His new line of work led, indirectly, to planes crashing and body parts raining over his neighborhood. As a consequence of Walt’s choices in the fictional TV-years between his 50th and 52nd birthdays, other men’s daughters died, drug dealers died, crime bosses and old people and kids died. His world and home became ruinous. Until the end, he kept saying he was doing it, cooking meth for his family – that he might leave money for his wife, disabled teenage son and infant daughter.

In the end, he couldn’t repair his relationship with his teenage son, who’d idolized him. He couldn’t bring to life his former student and partner’s dead lover. Or resurrect others he’d killed along his strange, calculating and horrifying journey. Walt died in a bloody scene, right along with the professional bad guys, the hit-men he’d hired to get at others.

Someone close to me suggested the ending was “too good” – that Walt’s fit of honesty in an i-dotting finale offers a sense of catharsis, or redemption, that doesn’t follow from the antihero’s trail of heartless decisions. It was unlikely, he said. Unlike Heisenberg.

But I loved it.  A lot. Mostly because in my real life, I’ve seen people nearing death who lacked the courage to contact loved ones, to say a few words that – while insufficient to fix what’s irreparable – might have helped them gain peace of mind, or future solace. On the other side, I’ve seen family members and long-lost  friends afraid to call or visit patients on their death beds, for not knowing what to say, for not being able to set things perfectly right.

Sometimes there’s no way to mend a person or a bad situation. You can’t deny reality. But if you’re still conscious and able to communicate, you may be able to lessen the damage you’ve done, or the pain someone else is experiencing, just a bit.

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Living Like It’s Shark Week, Take 3

It’s Shark Week, or at least that’s the situation over at Discovery Channel. The annual, virtual immersion into the world of cartilaginous fish has been adopted by your author as some sort of metaphor, but she’s not sure for what.

“Live every week like it’s shark week” is a puzzle. In fact, this statement in a 30 Rock episode lurks at the periphery of Medical Lessons year-round. By now I should confess I’ve never watched an entire Shark Week program. But that doesn’t stop me from wondering about the significance.

Remotely, it’s about mental health. Science, too. I could head into a discourse on cartilage and the alleged beneficial effects for illnesses like cancer, but I don’t believe there’s any evidence to support those claims. Surely, Shark Week has to do with whether you embrace more risk or take a safe route, swim where divers go or watch TV about nature. At another level, it’s about time – a reminder that there are only so many days and nights in each week, in each month, in each year, by which we mark our lives.

So it’s about mortality. Maybe.

An alternative theory is that Shark Week is entirely devoid of deep meaning. It could be nothing more than a tool by which the Discovery Channel turns a profit in August. This year, the event was delayed until August 12. Although I’ve never taken a course in cable network programming, I would hazard a guess that this scheduling change had to do with the end of the Olympics programming that same day.

For 2012, I’ve decided to celebrate Shark Week by not watching TV. Furthermore, I won’t write on anything that has to do with breast cancer or hard science. This morning, I walked to a beach and went for a swim before breakfast. It was fantastic.

Enjoy August! And please rest up, dear readers, because I’m likely to get serious again, soon,

ES

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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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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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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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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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