This week has been a difficult week. It’s one of those weeks that all oncologists have. If you work long enough in this field, you have days or weeks or even months where it seems like every time you are in the office you have another death certificate to sign or the next patients you see seems to have a relapse of their cancer.
The week started with a relapse of a patient with acute myelogenous leukemia. I had seen her on her one year anniversary of her finishing her last round of consolidation chemotherapy and she was doing great. We were so hopeful that day. That was just a few short weeks ago. Earlier this week she came in with cold-like symptoms and her blood counts were abnormal. Bone marrow aspirate and biopsy confirmed that her leukemia is back She is back in the hospital receiving chemotherapy in order to try to, again, get her back in remission. She is one of those women that have an ever-positive attitude. To face life with such strength, conviction and humor is a wonderful blessing. I really, really wanted her to be one of the few patients with leukemia who I cured. Now she is face months more of chemotherapy and hopefully a bone marrow transplant.
Another patient who I hadn’t seen in over a year and a half, because of insurance problems, came into my office. She’s a young 30-year-old female who I treated for breast cancer approximately two years ago. She had very early stage disease and did so well with her chemotherapy. She should be cured!!!!!! She was having some right upper-quadrant abdominal pain which seemed consistent with gallbladder pain, however, blood work revealed elevation in her liver function tests and elevation in her breast cancer tumor marker. I’m afraid that her CAT scans which will be back soon are likely going to show evidence of metastatic disease. I just have a difficult time believing that such a young women is now dealing with a terminal disease.
The week ended with another man relapsing from his leukemia. He is the father of four and recently adopted two nephews who had needed a home. He has been working two jobs for the last year to support his family. He too is back in the hospital receiving chemotherapy.
Also this week I saw a young man, 19-year-old who presented to the emergency room with abdominal pain and was quickly diagnosed with a colon mass, which was resected. It turned out to be a high-grade sarcoma, which is a very aggressive, difficultly cured tumor. He has a very long road to go. I had no answers for his mother as to why such a young man developed such an awful disease.
Three patients who I have treated, each of them for over five years passed away this week. In signing their death certificate and writing a diagnosis of colon cancer, lung cancer and ovarian cancer, once again brought the point home to me that we’re still so far away from being able to cure cancer. All three of these patients had over the years become more than patients to me, they had become my friends. I knew about their families, their children and their grandchildren. I knew about what was important in life to them. My sadness was only blunted by the fact that I now know that they are relieved of the discomfort they were having due to their cancer. I also know that I did my very best for them. I also know now they are in a better place.
There was a recent article in one of the oncology magazines about the high rate of burnout that is found in oncologists. In the article they talked about having the realistic expectations, managing one’s time and wisely having interest outside of the oncology practice. Working in quality improvement to try to better your practice and continuing to be educated seemed to reduce the burn out. They found that one of the most consistent and one of the most pervasive symptoms of burnout is the loss of empathy for an oncologists patients. If that’s true, at least by the way I feel about the patients that I have worked with in the last week, I know I’m not burned out.
There are a large number of people who contribute to care of patients, each of these people contribute something vital to the well being and care of our patients. One of the most important and often overlooked groups of people is the pharmacists. Today as the number of new drugs that are on the market increase, and the number of drugs patients are on increase, the role of the pharmacist has become evermore important. Drug interactions can be life threatening. In general; physicians do a relatively poor job at policing a patient’s medicines for possible interactions. Physicians rely on the fact that we have a safety net in our pharmacists that serves our patients.
Pharmacists play additional roles throughout the healthcare system. You find pharmacists in our local pharmacies, but you also find them in our cancer centers, in our universities and in our hospitals. Nearly everyday that I am on call I speak to a hospital-based pharmacist about drug interactions, drug levels, dosing of chemotherapy and the generalized care of patients. In oncology, the chemotherapy regimens are complex and difficult to administer. As new drugs come onto the market, many of them have unusual and new side effects. As a practicing oncologist, I rely heavily on the pharmacy staff that we have in my office, the special pharmacists and doctors of pharmacy (PhD’s) that we have at the hospital to help make sure that these new drugs and new complex regimens are given correctly and safely to our patients.
Recently in the United States, there has been a huge push to document eliminate medical errors. Hospital-based pharmacists are the frontlines of these efforts. Hospitals that are the best, and give the best care are those ones that not only have a good nursing staff, but also have a good pharmacy staff. Patient’s must understand how important the pharmacy staff is in their care and seek out pharmacy expertise whenever possible. This should happen whether they are just picking up a prescription from their local pharmacy, if they are in a hospital battling an illness, or at a cancer center receiving chemotherapy.
Today a patient’s wife gave me a wonderful gift. This gift probably meant more to me than any other gift I have ever received. Over the years, I have been fortunate enough to have patients give me quilts, thank-you cards, desserts, crates of oranges, boxes of apples, Christmas ornaments. My patients’ generosity has always amazed me and made me feel some what uncomfortable. I feel that it is so unnecessary to give these things to me. This is my profession and I love taking care of them. Some of the most wonderful gifts that I have received have been pictures of children, grandsons and granddaughters, great-grandsons and great-granddaughters. Other wonderful things I’ve received have been the letters and cards of thanks. I have tried to keep all these gifts over the years.
The gift that I received today, however, was one of the most amazing that I have ever received. This wife’s husband is a gentleman that I have seen for the last couple of years. He has been fighting metastatic lung cancer. Calling him “gruff” would be an understatement. He is not always the easiest patient to take care of. The relationship they share is wonderful. She takes wonderful care of him. I have come to feel very close to the both of them. This patients’ wife gave me a gift with a note to my family and my wife thanking them for allowing their dad and husband to spend time taking care of her husband. This was totally unexpected and really touched my heart. That she would think about how, as her husband’s oncologist, that the time that I spend in the office would take time away from my family was so thoughtful. I had a little bit more spring in my step after receiving this gift and was proud to share it with my family
One of the most disturbing trends that I have witnessed in the last few years is the development of hospital-based comprehensive breast cancer clinics. These so called comprehensive breast cancer clinics are designed primarily by hospitals in order to keep breast cancer patients tied to a hospital setting and so that the hospital themselves can refer patients within a selected or a favored group of physicians. This is not always what I would consider best for the patient.
Here’s how it works:
Many mammograms are done at hospital-based mammography unit. In the past, a mammogram would have been ordered by a primary care physician. The primary care physician would then get the report of the abnormal mammogram. Then in consultation with the patient, the primary care physician would have referred that patient to a surgeon of his choice for the biopsy, or would have set up a needle biopsy under his direction at the hospital. Today in these comprehensive breast cancer clinics, any women that has an abnormal mammogram is being immediately informed of her results and referred to a surgeon of the hospital’s choice without any input from the ordering physician. This is justified by the idea that the faster the diagnosis is ruled in or out the better for the patient. This directs these women to hospital-based services and, in many cases, is cutting out their primary care physician’s input on surgeon choice, on oncologists choice and of radiation therapist. This is more based on money than what is best for the patient.
A situation arose recently in one of my patients who I have followed a long time for colon cancer. I had seen her for her routine follow up appointment for her colon cancer six months ago, talked to her about routine health maintenance scheduled a mammogram which was recently done. The patient’s mammogram was abnormal and she was referred to a hospital-based surgeon and biopsied before I received the initial report of the mammogram. Unfortunately her biopsy turned out to be positive. I believe that she would have been better served by having me discuss with her what an abnormal mammogram might have meant. I believe this patient would also have been better served if I as the ordering physician had an opportunity to speak to her about the competency of the surgeon that she was referred to.
These “breast clinics” that hospitals now are using are completely economically driven. It is an attempt to keep control of patients and their diagnoses and refer to physicians who utilize hospital-based services more than other physicians who may use different surgeons or different outpatient facilities. Is the care the patients receive in these clinics inappropriate? In most cases I would say no. Patients receive their biopsies quickly, and most biopsies are benign, but I feel that by cutting out the primary care physician, or the primary care oncologist they are depriving a patient a valuable opportunity. Discussion and consultation with physicians who may know them better than any other physicians can not be underestimated. These clinics are preying on women’s emotions, and their fear of cancer. The idea that a patient has an abnormal mammogram and needs a biopsy as soon as possible is appealing to women. This may, in some cases, not be absolutely necessary and/or may be better handled by physicians that know the patient better. Whenever I talk to women about mammograms I encourage them to understand that the majority of abnormal mammograms when biopsied are benign. Getting input from whatever physician knows them the best in terms of what surgeon to use to do the biopsy or consideration of a needle biopsy is very important. This is something that they should discuss with their primary care doctor or a physician that they have a strong relationship with. Patients need to realize that the rush to biopsy and the rush to get them involved within a “comprehensive breast cancer clinic” is very much economically driven.
I just got back from the American Society of Clinical Oncology meeting in
It wasn’t just the speakers that drove home the point of cancer being a global disease and the war against cancer being a global effort. There were doctors and researchers from every part of the world. There were people from
One of the greatest issues that are facing our country today is the issue of paying for healthcare costs. It is an issue that has been well publicized in the presidential campaigns. The talk of universal healthcare has been debated extensively and will likely play a role in the upcoming presidential election. I have always, in my practice, tried to practice with blinders on ignoring a patient’s insurance. Whether a patient has Medicare, private insurance or Medicaid, I have always tried to treat them each with the same standards. However, this is a somewhat of a naïve sediment. Unfortunately, a patient’s insurance does matter on what treatments they will and will not get. It will also matter on how timely and how easy getting these treatments will be. Patients with Medicaid have an extremely hard time of getting good care. Many surgeons, urologists and other specialists don’t accept Medicaid. Trying to get patients proper care is sometimes difficult, if not almost impossible. There are different private insurance companies that take a much more difficult stance in terms of covering patients for certain therapies. This is especially true with oral chemotherapy agents. Some of the newer and most exciting drugs that have come onto the market in the last 3 years have been oral chemotherapy drugs. Drugs such as Sudent, Xeloda, Tarceva and Nexovar have been found to be effective in multiple malignancies; however, most oral chemotherapy is handled like any prescription drug. This sometimes leaves patients with no coverage or huge copays that prevent them from being able to afford these kinds of drugs, Medicare part D also, in many cases, prevents patients from being able to afford these drugs. These Financial situations have sometimes changed what a therapy a patient might get, and have at times influenced a patient’s decision of whether to proceed with therapy or be admitted to hospice.
As a practicing oncologist, I find it difficult to truly know what the best answer for our country is. It concerns me that our country is already struggling to pay for the advanced heath care that we have. New drugs and new therapies will continue to put pressure on our country’s ability to pay. It will certainly be interesting to see how the presidential campaigns go. I think healthcare and how to pay for healthcare should be one of major topics discussed between now and November. I encourage everyone to think long and hard about this issue.
A patient of mine returned from being evaluated at famous clinic in this country. I would consider this clinic as a alternative medicine clinic. The recommendations that were given to this patient for therapy really angered me. There is a great difference between practicing oncology based on scientific evidence and practicing oncology based on what sounds good or may seem exciting & trendy. So many times patients return from tertiary care facilities, or alternative care clinics with recommendations for treatment that have no scientific basis. This leaves local oncologists to try to:
1) Get patients insurance companies to approve these medicines
2) Leaves these local oncologists in the situation of trying to explain to patients why the so called “leaders in the country” are recommending unproven therapies.
This is a very difficult situation for an oncologist to try to deal with. Patients want the latest and greatest therapies, but what patients don’t understand is that many times these new drugs, or new combinations that are recommended are found later not to be effective. They end up, when fully evaluated, to be found to have higher toxicity with no greater chance for cure or survival.
There is a movement in the
I always tell patients that are going to a referral cancer center to ask hard questions of the doctors that they see, questions like “has the therapy you’re recommending been proven to be better than the standard of care?”, “what are the extra toxicities associated with new combinations?”, “will my insurance company pay for it?”. It is so easy for these centers to make these recommendations knowing that they don’t have to worry about the possible complications and trying to get chemotherapy covered by insurance.
I encourage all my patients to get a second opinion. If they have any questions about their therapies, I believe that second opinions ultimately make the patient a better patient. But when patients seek a second opinion, I try to educate my patients on how get the most out of the second opinion. This requires some work on the patient’s part. I believe they need the following:
1) They need to have as much information about their disease as possible, either from the internet or other sources.
2) They need to write down a list of specific questions that they want a second opinion to answer.
3) They have to be ready to ask hard questions, such as, “what is the cost, what is the toxicity, why is the regimen that you’re recommending better than the standard of care and how has that been proven?”
By asking these questions, they can truly evaluate whether the recommendations that they are getting are superior to the recommendations that they have received from their local oncologist.
Patients my practice frequently ask me what they can do to help themselves in battling their cancer. I usually talk about diet, exercise, healthy lifestyle. Another thing I also discuss with them is how there is now greater information about how ones social environment and stress can make people vulnerable to cancer. A number of studies have suggested that chronic stress can contribute to the development and progression of cancer. Recent studies have taken a more in depth look at trying linking stress to cancer. Using data revealed by patient interviews, specific biomarkers & hormones and other biological cues produce by the body in response to stress they have been able to show that chronic stress may contribute to cancer development. This is important because it is thought that these same biomarkers are also involved in fueling tumor growth. There have been studies that have shown that stress hormones actually protect lab grown tumor cells from the effects chemotherapy. One of these biomarkers called VEGF, or vascular endothelial growth factor, stimulates the growth of blood vessels and tumors. There have been studies in mice that have shown that tumors found in stressed mice had significantly more blood vessels than tumors seen in non-stressed mice. Researchers also found that tumors in the stressed animals were more aggressive and more likely to metastasize.
With all this developing data I think it’s important that patients look at stress reduction as a means of fighting their cancer. I think it is important as physicians that we consider using drugs that combat the negative effects of stress. Physicians should encourage patients to eliminate social isolation either through family members or the use of support groups. Dealing with the stress of a diagnosis of caner is very difficult. Some patients are unable to deal with this stress. I believe this some times contributes to the poor outcomes we see in some patients. Stress reduction and making life choices in which promote a lowering of a patient’s stress levels are important topics to discuss in an overall strategy of taking care of patients. This is an important area of continued research and already a beneficial strategy that should be incorporated in survivorship programs for cancer patients.
One of the questions I have always been asked when they find out I’m an oncologist is “how can you work in such an area that so many people die?” I usually answer them this way: The first thing is that the majority of patients diagnosed with cancer today survive, they’re cured, they go on with the rest of their lives and are able to live out healthy, meaningful and productive lives. This gives oncologists great satisfaction. The second thing I always tell people is that you have an extraordinary opportunity as an oncologist to get to know your patients. Spending time with them, understanding what their lives are like is so enjoyable. I am able to see my patients much more frequently than almost any other medical specialty. I may see a patient with breast cancer weekly for months, and this gives me the opportunity to establish a relationship that I would otherwise not be able to have. This opportunity wouldn’t if I was in internal medicine, or cardiology or some other specialty.
The other thing that I tell patients is that I don’t view death necessarily as a bad outcome. Death is something that is a very human experience and is something that is universally shared by all of us. The bottom line is that we are all going to die. Dying of cancer is only one of the many ways in which people go from this life into the next. As an oncologist, I believe that my skills in helping patients go from this world to the next with as little pain and discomfort is probably my biggest challenge I face. This area of oncology is called palliative care. It’s basically the care of patients who are in the last months of life. It involves primarily symptom control and comfort care. This has always been an area of great interest and also an area of great pride for me. I believe that I have done a good job in relieving patient’s suffering as they approach their death. Palliative care has grown as subspecialty in medicine. It is also an area of focus within oncology. It is somewhat still in its infancy. Palliative care programs have been established at many hospitals. They provide a great deal of comfort in the patient’s lives that they come in contact with. However, we still have a very long way to go. It maybe interesting to know that many oncologists find having conversations about ending treatments or the end of life issues very difficult. You would expect that men and women who have spent their lives treating patients in oncology would have developed expertise in these kinds of conversations. Unfortunately this is not always true. In my own practice, we are working diligently to develop a practice wide palliative care program. Hopefully this program will help patients be treated aggressively for symptoms related to their end of life.
Lastly, I find oncology a very rewarding field, both spiritually and emotionally.
This comes from a great faith in God and a sense of God’s purpose for people in this world. I believe we are here to help each either to do good in this world wherever possible. I believe that I may do more for patients who are dying of their cancer than those patients who ultimately are cured of their cancer.
Over the last 15 years I have had patients whose prognosis from their cancer should have not allowed them to live for a lengthy period of time. I can’t explain why some of these patients have lived and survived. I believe that their survival is more related to their faith, strength of character and determination than any thing I have done with chemotherapy, surgery or radiation therapy. When people ask me if I believe in miracles, I’m always able to answer that I have a practice full of miracles and I truly believe this. Here are some of their stories………
One of the first patients that I ever saw as a brand new practicing physician is “Christy”, she presented to my office on the very first day of my joining my current practice. She had been feeling poorly for several weeks, and she complained of widespread bruising. I quickly had a complete blood count drawn that showed that all her blood counts were severely low. I admitted her to the hospital and a sampling of her bone marrow showed that she had a disorder called aplastic anemia. She was in her mid 60’s at the time and her prognosis would have been considered quite poor. She went through specialized therapy and had multiple complications of her therapy and really, in my initial expectation was that she would not survive. She fought infections, bleeding and a lengthy stay in the hospital. I just saw her yesterday, 15 years after her diagnosis. She and her husband continue to travel. They have been to
I met “Judy” after she had a seizure; I was immediately struck by how young she was and how strong her personality was. An MRI was done which quickly revealed a large brain tumor. The tumor was biopsied, and it was determined that she had the most aggressive form of brain cancer. People with this form of cancer have a prognosis that is measured in a few months despite aggressive chemotherapy and radiation therapy. Judy immediately focused her energies on her treatment and told me from the beginning that she was going to be a survivor. “God is going to help me get through”. She always said that she had too much to do, too many people that relied on her and too many things that she had yet to do. Remarkably her tumor went in complete remission and for the next 10 years she kept her promise to herself to live every single day the best that she could. She showered her family with her love and grace, volunteered excessively and was proud to be a cancer survivor.
I met “Mary” in my office after she was diagnosed with stage IV lung cancer. I again felt like her prognosis was that of only a few months survival. After talking to her about chemotherapy she immediately went to work fighting her cancer. She never once complained about any side effects of her therapy, even though there were many. Her positive attitude and strength of character shown through every time she visited the office. Little by little, with each successive round of chemotherapy her tumors involving her lung and liver slowly resolved. I was excited to give her the news that her CAT scans showed complete remission. Unfortunately in my heart I could almost guarantee that it wouldn’t be long before her disease returned. Ten years later Mary continues to be active in cancer support groups, continues to take care of her ailing husband and still makes my office shine when she comes for her now too infrequent visits to my office. She volunteers for many cancer related charities and is an active member of multiple support groups.
I also met “Ray” early in my career. He was diagnosed with multiple myeloma. I would describe Ray as a simple man, country boy, hard working with a deep belief in God and himself. Unlike some of the patients described above, Ray’s initial treatments didn’t go well. His disease progressed despite the treatments I prescribed for him. In a last ditch effort, he was referred for bone marrow transplant. His expected prognosis, even with his transplant, would have been one of just a few months to a year. Today, 9 years after his transplant, Ray continues to work his farm, continues to enjoy life and smiles when he comes to my office.
The common theme in these patients, I believe, is their faith in God, strength of character, and their determination to overcome their disease. Something has allowed them to survive far longer than what their diagnosis and/or initial prognosis would have indicated. These are just a few of the patients in my practice that I would consider miracles. There are many other patients who, although they eventually died of their disease, I would add their name to this category. This is because of their ability to survive beyond what we would normally expect cancer patients to survive. Approaching their cancer diagnosis as these patients have, I believe has more to do with how long a patient survives than all the therapies that they may endure. I thank God because he gives me the pleasure of watching these miracles happen.
