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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Cathy Tells Future Cancer Docs to Shut their Laptops and Speak Plainly

I stayed up last night watching the Big C. The latest episode, The Darkest Day, takes place on Dec 21 at the end of the show’s pseudo-fall second season.

Here, two things happen of above-average interest to this doctor-patient-viewer:

First, the characters’ usual and crude shenanigans are interrupted by Cathy’s visit to a class of future cancer doctors. (Can we say “oncologists”? No, it’s too big a word for this program.)

Second, Cathy aborts her family’s planned vacation to stay with her friend Lee, who’s dying. Her decision to stay with Lee is perhaps the most interesting, and controversial, decision she’s made so far, but I won’t harp on this, because how can anyone judge what she’s doing?

The lecture scene:

Dr. Sherman (Alan Alda) “presents” Cathy (Laura Linney) to his class, a group of diverse young people most of whom are taking notes on (Apple – another story) laptops in a small lecture style room. The thing is, anyone who’s been to med school, or residency, or fellowship in oncology, could tell you that’s not how students meet or learn to interview patients.

Cathy rants, and in a rare surfacing of her anger at her disease, she yells at them to stop typing and look at her. The message is that cancer patients will trust them with their lives, so they should get to know their patients, and spend more than two minutes with them in a visit, or else go into another field.

It’s not a great speech, and it’s misdirected besides misguided. Most of the medical students I know and work with are warm human creatures who aspire to be caring physicians, and they do look at patients in the eye or try to do so, especially early on in their training. But the show’s off again: typically the students, or oncology fellows, wouldn’t be meeting a patient in a class like this, but on a ward, in a patient’s room or nearby lounge, and the real issue is that the patient would be physically demeaned by a hospital gown. All of this is missed -

Two students ask questions before Cathy gives it to ‘em. One asks about her trial and, tellingly about this show, she can’t answer so the Alda character fills in. He explains that she’s getting an experimental drug (still no attempt to inform viewers about the trial she’s on) and some “chemotherapy” (still, no mention of what she’s getting; please tell us – we, the audience can handle that tiny bit of information.) Then another student mumbles a question even I couldn’t understand, I’m not sure if it was in medical English or Latin, or something else, and Cathy flies off the handle about medical jargon.

The point of Cathy’s spiel, that cancer doctors should look at people in the eye and speak plainly, because patients rely on them, is fair but obvious. No argument, but no deep insight award, either.

The problem with communication in medicine is that there’s a big gap between only using words like “mole” and “clinical trial” and delineating details on how braf mutations influence a melanoma patient’s prognosis. Cancer’s terms are part of our culture’s lexicon now, or should be, to some extent, in med school and on programs about ‘the Big C.’

The directors have dumbed this down to a point that there’s no information at all. If real doctors did that, patients could not make informed decisions.

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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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The Big C Continues: on Family Life and Friendship, Season 2, Episode 10

A Labor Day break in broadcasting afforded some respite from the Big C. The latest episode continues with its focus on normal and not-so-normal life among Cathy’s family and friends.

On the family front, her teenage son “Adam” goes with the woman he met on-line in a cancer kids’ support forum to her high school reunion and has a good time there, despite a strange blip in which she calls from the ladies’ room and asks him to buy her tampons. Cathy’s brother, said to have manic depression but to this doctor-TV-critic seeming more like a schizophrenic, continues to deteriorate off his meds. Cathy’s overweight husband buys a fancy scale with a computerized voice that tells him his “metabolic age” is too high.

About cancer, there’s little on screen: Lee, Cathy’s “cancer friend” and clinical trial companion, is coughing, but that detail goes unmentioned. He mentions that Dr. Sherman, the clinical trials oncologist, wants to see him because he has “more tumors.”

“My tumors are shrinking,” Cathy reports.

And that’s about as much detail as we get about her treatment and evaluation for advanced melanoma.

Château Lafite Rothschild

Toward the end of this episode, Cathy appears at Lee’s apartment with a bottle of wine, not quite the 1982 Lafite Rothchild on his bucket list, but enough for them to drink again and share secrets. She says she feels “buzzed” as he opens another bottle, which may be as revealing about how some people cope with illness as is anything else on this show, so far.

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Cathy Attends What Friends Think Is Her Funeral

Last night’s episode of the Big C may been the strangest yet. What happens, more or less, is that Cathy (Laura Linney) gets to attend her own funeral.

This odd situation arises because Cathy’s old, recently-pregnant friend (Cynthia Nixon) miscarries the child who would have been named in Cathy’s honor. Through a series of errors including miscommunication attributed to Twitter, some of Cathy’s childhood friends think that she has died. They arrive at the memorial service for the unborn child, thinking it will be Cathy’s funeral.

So the sad gathering turns into a weird reunion for people who care about the protagonist, along the lines of fulfilling a psychological fantasy about seeing who’d show up at one’s funeral, replete with the message that “life is short” and you shouldn’t wait to do what makes you happy.

No news, still, on Cathy’s melanoma, treatment or progress -

This show may lose me. I’m not sure how many more episodes like this I can watch.

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A Miserable Episode of ‘The Big C’

I found it hard to stomach yesterday’s Last Thanksgiving episode of the Big C.

Besides that it’s August, and ill-timed, the show was just plain awful. (Sorry, Showtime, but if you don’t get this patient back on track you’re gonna lose her.)

Cancer was absent again. But I really want to know: What drug is Cathy on? Is it intravenous? Is it a pill? How often does she take it? Is she anemic? Does she have mets in her liver? Does she have pain? Give the audience something real to wonder and care about, please. Even one, meaningfully-informed treatment decision would be welcome. I have full confidence Laura Linney could handle the discussion, and more.

The only reference to the drug is that Cathy’s fingernails are falling off, said to be a side effect of the drug. So as not to make her cancer friend jealous, she covers the tips of her fingers with fake fingernails. He catches on, and gets angry.

(Oncologist’s note: side effects of cancer drugs don’t necessarily or usually correlate with efficacy; nails falling off is not common melanoma drug toxicity, including for experimental drugs I read about on-line. So this point is misleading.)

The family’s medical bill nightmares are legit, but who with cancer (or any serious illness) would want to watch actors contendwith arbitrary and headache-inducing paperwork?  The show starts with Cathy’s husband, Paul, complaining about a $3,000 bill the insurance denied retroactively. No explanation is given. During the meal preparation, the document is destroyed by deep-frying.

The Thanksgiving dinner was a disaster, in case you were wondering.

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Life on the Big C – Cathy Tries Acupuncture and Visits a Gay Bar (Season 2, Episode 7)

This week’s installment of the Big C starts, promisingly, in a medical facility. A nurse or technologists notes that Cathy, melanoma patient extraordinaire, has high blood pressure. The plan is that Cathy should try to relax, and she’ll speak with “the doctor” next week about possible pills for treating the hypertension.

When she leaves the clinic we have no inkling about the protocol or what kind of experimental treatment she’s getting.

At the Bear Bar ("The Big C" Season 2, Episode 7)

Lee, Cathy’s friend in cancer-land on the show (portrayed by Hugh Dancy), suggests she try acupuncture. She’s open to this, of course. The duo go to an odd place where a woman inserts needles into Cathy’s head while telling her about chi (aka qi) and medical terms like anastomosis and symbiosis. This viewer learned that these words can apply to interpersonal relationships and connections between people. Great!

Here again, the show’s participants do summersaults to avoid talking about science.

The highlights of the episode are two: Cathy and her husband Paul (Oliver Platt) go to a bear bar with her friend Lee, who’s gay, and drink $2 beers in a wild-and-crazy night out. Meanwhile Andrea (Gabourey Sidibe), Cathy’s obese and attitudinal pupil–turned-houseguest, goes out on a date with Myk (David Oakes), a somewhat handsome and decidedly ambitious Ukranian TV salesperson. The scene when the two have a romantic dinner is so unexpected and unlikely that somehow I found it credible. He likes big things, he explains, as if the show’s director feels his character needs justify his attraction to a large woman.

In the final scene, Cathy’s in the bathtub having phone breathing therapy with Lee, when she’s visited by a vision of her former, now-dead neighbor Marlene and then notes that her (real) fingernails are receding. It’s a sign the drug’s working she tells her husband. They hug and cry.

I guess this is a show about life being weird when people have cancer, which is fine. But the Big C’s still in the closet, it seems.

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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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Cathy Bonds With a Fellow Patient in the Big C Season 2 Episode 5

Last night I stayed up to watch the Big C. Really it was a sleeper, except if you get excited when Cathy’s teenage son hires a dominatrix and then can’t pay the bill.

Cathy's son in an experimental phase, Showtime's "The Big C"

On the cancer front, there’s nothing new to report. We still don’t know what kind of treatment Cathy’s getting. The only “medical” topic is the uncovered cost of some procedures, like $1800 for an MRI, and her husband’s lack of an insurance-carrying job.

Emotionally there’s some development in this episode. Cathy befriends a young man, another patient on the clinical trial. The two talk about life and death in a college dorm-y way. They go to his apartment and get drunk. Wow.

This can’t be as deep as it gets.

Feels like a long season, already. As I said last week, I’ll stick with the show because I said I would, for this year at least. Maybe it’ll get better – in terms of the plot, if it doesn’t become more informative. But I’m starting to lose confidence in the program’s value.

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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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The Big C Tries to Get Sexy

Last night’s episode of Showtime’s The Big C - Season 2, Episode 3 – was about sex: high school sex, pregnant woman with her manic, now-medicated boyfriend sex, marital sex, masturbation sex and marital sex. And that was about it.

Laura Linney's character looks at the man portraying her husband, in "The Big C"

Cancer and sex is an important topic, but I think it could have been handled better with a more focused, subtler study of the relationship between the patient and her husband during a period of illness. (The image with Cathy’s glance, above, is about as revealing as the story gets, in terms of Cathy’s feelings and her husband’s coping strategy – which is to keep busy with superficial activities.) Nestling their struggle with intimacy between the other, kinky and adolescent stuff in the episode distracts, clumsily, from the genuine issue.

My main disappointment with the show is, still, the lack of information about Cathy’s melanoma treatment. In this episode she takes steroid injections to avoid side effects from the clinical trial drug. But we’re told nothing about the research study or how she learned about it. Presumably the protagonist, our hero, has signed informed consent by now, as she’s on “the trial” and taking steroids as part of a protocol. That discussion – Cathy’s meeting with the oncologist and others in his staff, her reviewing on-line information or other resources, and her questioning him – would have been worthwhile.

Maybe that’ll happen in the next episode. Meanwhile we’re in the dark about the specifics of her experimental melanoma treatment, why she chose to participate in the trial, and how well she understands what she’s signed up to receive, if at all.

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Cupcakes (and cancer) for Cathy – Big C, Season 2, Episode 2

The Big C stepped it up a notch last night, with a much better episode.

In the first scene Cathy, played deftly by Laura Linney, returns to the school where she works. She finds the kids are selling cupcakes, each decorated with a “C,” in a fundraising effort that’s intended, somehow in a manner unspecified, to help her cause. Her son’s getting lots of warm attention due to her illness.

Cathy appreciates it when one of her students, Andrea, portrayed by the actress Gabourey Sidibe, says, directly, “You don’t look good.” To this the protagonist responds with an immediate: “Thank you;” she’s glad that someone’s being honest with her.

Laura Linney and Oliver Platt in "The Big C"

Next, in perhaps the most credible scene so far, Cathy and her husband drink scotch while pouring over her insurance bills and writing checks for co-pays.

The show moves on to the appointment with the fictional famous Dr. Sherman, in the figure of a now aging Alan Alda. He’s got a clinical trial going on for melanoma, and Cathy wants in. Another patient tells Cathy that preliminary results for the new agent, based on studies in Europe, are promising.

But after so much waiting, Dr. Sherman turns out to be an abrupt sort of guy. He works charms by playing magic tricks for sick children, but otherwise is a personal dud. Cathy’s disappointed, but in the end might receive melanoma treatment under his care. She makes one request of Alda’s character: to be honest.

So there’s an emerging theme: The cancer patient portrayed by Laura Linney wants her students and doctors, and presumably everyone she knows, to be straight with her.

Tell it to me like it is, no nonsense…

(I think this is an important message, about honesty with people who are ill, but it’s not necessarily appropriate or right for every patient.)

Things change, of course – as in any TV “comedy,” and it ends like this: Cathy’s left with hope at two levels: her brother’s having a baby with her best friend, and so she’s soon to be an aunt, and she will get a cancer treatment that might help her to live longer.

Still, what this oncologist-patient-blogger’s waiting for is “The Big C” to dive into some real, hard and science-y medical decisions, with clear dialogue. The show’s failing in this dimension. How can Cathy sign consent for a clinical trial next week if she’s never heard any of the terms? So far, we haven’t heard a whiff about Braf.

We’ll see, and I’ll stay tuned.

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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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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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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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Does Cathy Make the Right Cancer Treatment Decision in the Big C?

scene from season finale, The Big C

“I don’t want to get sicker trying to get better and then just end up dying anyway” – Cathy, the 42 year old protagonist with advanced melanoma, on the Big C.

ML’s incoming search data suggest that some people out there are very determined to know exactly what happens to Cathy in Showtime’s new series about a young-seeming, middle-aged woman with advanced, presumably stage IV, melanoma. In last week’s review I elected not to give it away. Now I’ve reconsidered. So here’s a spoiler alert: Don’t read this post if you don’t want to know what happens to Cathy at the end of the Big C‘s first season.

After months of unusual and comfort zone-breaking behavior, Cathy reconsiders her initial decision to forgo treatment. She, possibly influenced and clearly supported by her husband’s enthusiasm for her middle-aged life and continued existence, indicates that she’s willing and ready to try treatment with Interleukin-2. Cathy seems to know something about the FDA-approved drug, which is generally toxic and ineffective in most melanoma cases. At one point, she lists its putative side effects, according to the show: “burning scabs all over my body, constantly throwing up, fluid on the lungs, my veins could shut down, I could die on the table…”

Nonetheless she decides to accept treatment:

“I’m gonna hang on as long as I can. And I’m going out ugly,” says Cathy, played by the actress, Laura Linney.

“It will never be hard for me to look at you,” responds her supportive husband Paul, portrayed by the actor Oliver Platt.

At this point Cathy’s hoping the Interleukin-2 (“interlaken,” as her husband keeps calling it, perhaps metaphorically, subconsciously, or else just simply) will keep her alive for six months, when she might or might not be eligible for an experimental anti-melanoma drug in a clinical trial.

So she goes for it: in the final scene she’s in the hospital, her mind cloudy, and dreaming. You may wonder what I think of her decision.

As an oncologist I’m half-relieved. The patient will, undoubtedly, die too soon – within months or a year or, if she’s lucky, maybe two years or even longer – because you never really know for sure about these things, if she doesn’t take any treatment. Deaths from metastatic cancer can be unpleasant and painful. On the other hand, conventional therapy for stage IV melanoma rarely leads to complete remissions and, essentially, never cures the disease.

I admired that the patient, until this last episode, maintained such a no-nonsense approach to her condition. Her perspective seemed more mature than her oncologist’s. Despite her weird and nearly unraveling behavior, she’s clearer in her priorities than many patients I’ve known; she seems to understand that a treatment might give her a few additional months but is very unlikely to help her get well and, likely, would make her sick for the duration of her life.

Sometimes oncologists get carried away with hope. What I liked best about the story is that she, the patient, was realistic in this. She didn’t want to take toxic medications in desperation, without reason.

As a patient, my feelings are mixed, too. I respected Cathy lack of passivity in her decision. Accepting treatment initially would have been the easier, “normal” thing in our culture. In effect, so far, Cathy’s taken control of what happens to her body. At the same time, I couldn’t help wonder – what if she tried it? Maybe there is a cure in the pipeline, and she’d be eligible for an experimental agent in a few months, and that drug would help her, and she’d live beyond middle age, or at least until she’s 45 or 46.

Today is Monday, but there’s no new Big C episode because the season’s over. We won’t know how Cathy fares with the Interleukin-2 for a while. Even though she is just a cable TV character, she’s in a position to teach us about oncology and living with cancer.

Hopefully the show’s producers will provide insights into immune treatments, targeted agents, clinical trials, informed consent and palliative care. (I will consider Interleukin 2 and melanoma in a separate post, to follow.) But given the TV scenario, do you think Cathy’s made a sound decision?

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First Season Ending of the Big C

Last night I stayed up late to see the season finale of the Big C. For the first time in watching this series about a 42 year old woman with advanced melanoma, in a near-final scene involving the protagonist Cathy’s teenage son, I cried.

The storyline is moving, finally, in a real and not necessarily happy direction. I must admit I was disappointed overall with the program overall until lately. That’s not because Cathy behaved recklessly and irresponsibly upon receiving her Stage IV cancer diagnosis – her decisions are her personal business and a plus for my engagement. At least the program’s not too preachy.

My gripes are with the show’s other confused characters: her homeless brother, in a TV relationship with Cynthia Nixon’s spent, post-Sex in the City character, is so extreme in his strangeness, choosing not to shower for instance, he distracts from the narrative; her obese student, played by Gabourey Sidibe, seems like she’s stuck in the wrong program; her “oncologist” is so free with his time, and apparently has so little else to do (how about studying for his boards, if he still hasn’t any other patients besides Cathy?),  he comes across as a joke instead of as a credible and sensitive physician who’s completed his training.

The good news of course is Cathy, played fantastically well by Laura Linney. She’s amazing, perhaps more than ever, a good example of how women don’t have to be knock-out gorgeous to shine. Phyllis Somerville, as Cathy’s crotchety old neighbor Marlene, offers a revealing image of loneliness and dementia, with a bit of paranoia thrown in her mix. The two men in Cathy’s life – her husband and recent lover – provide a strange balance that somehow works around her: the lover is nice, supportive and easy-going; her husband is intense and devoted; his uber-love is persuasive. As for Cathy’s son, well, he’s grown on me over the past few months.

My favorite scene, easily, is Cathy dancing with a way-alternative cancer treatment provider, the Canadian “bee man” portrayed by actor Liam Neeson. How sad he must have felt, on the set, holding close a middle-aged woman in the role of someone facing death in slow-motion.

I don’t want to give the plot away, so I’ll just say that I will definitely keep watching the Big C. I can’t wait to see what happens with Cathy, if she’ll make it to the clinical trial that opens in six months and if she’ll be eligible for experimental therapy. This is no ordinary TV show.

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First Take On the Big C

Laura Linney as Cathy in The Big C

Last night I stayed up to watch the first episode of Laura Linney portraying a middle-aged woman in a new series called The Big C. The story is that she’s got a teenage son and a recently estranged, overweight husband who loves her. She lives in a suburban house that could use some work.  She teaches in a high school. She has a brother who’s deliberately homeless.

Her name’s Cathy – how ordinary can you get? Well, Cathy recently found out she has a terminal case of melanoma. In a change of pace, she expresses herself freely and does pretty much whatever she feels like doing.

For me, this TV situation has some big draws:

Laura Linney‘s a fine, not uninteresting actress. A few years ago she played a charming Abigail Adams in a history-minded miniseries. But I couldn’t bear to watch her miscast counterpart, Paul Giamatti, pretending to be President John Adams, so I didn’t. As in the storyline of the Big C, here’s an opportunity for Linney to shine.

Gabourey Sidibe, a young obese woman who stars in the movie Precious, may or may not be a fantastic figure on film or TV. She’s yet to be established beyond her debut and after watching last night’s episode I’m concerned already that she’s being “used” as an object for the protagonist’s preterminal beneficence. Still, she’s a definite plus.

The Big C‘s plot includes at least two “atypical” and potentially complex features. First, Cathy chooses not to take chemotherapy or other treatment. This intrigues me, and may be the show’s most essential component – that she doesn’t just follow her doctor’s advice. Second, she doesn’t go ahead and inform her husband, brother or son about the condition, at least not so far.

We’ve seen this non-communication before in movies (Susan Sarandon in Stepmom, for instance) and in real life, for most of human history. It’s too-easy for a blogger-patient-oncologist to forget that not long before our Facebook era, most people didn’t talk much about having cancer and even today, many patients prefer not to do so. Norms change.

If the point of the Big C is to broaden the dialog on cancer and talking about cancer, that’s worth a lot, still.

What’s wrong with the program? I think the doctor has some brushing-up to do about his image. He’s 31 and Cathy’s his first “case” – all of which is credible, but with the exception of an x-ray briefly revealed on the wall-mounted light-box, it’s not clear if he’s an oncologist or a dermatologist somehow offering her chemotherapy and pamphlets. His white coat is too short, in the style of a medical student’s. He uses few polysyllabic words. He looks well-rested and neat. In one strange scene, the patient and doctor meet for lunch at a pleasant outdoor restaurant. That’s not how oncology’s practiced, at least as I know it.

But I’m learning, too. And I’m wondering about the informational content of the doctor’s slick handouts, about which the protagonist, Cathy, has a vision.

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