March 2008 Archives
New patient
Today I saw a new breast cancer patient. When we see a new patient with breast cancer the medical oncologist is interested in finding out certain information in which to determine whether that patient is a candidate for the various treatment options that we use in breast cancer. In breast cancer, there are three major treatments that we use: we use radiation therapy, anti-hormonal or anti-estrogen therapy, and lastly chemotherapy. Which of these therapies we utilize, depends on the health of the patient, the age of the patient and what is found on the pathology in each patient’s case.
The first thing that I look at in a woman with breast cancer is her age. Breast cancer can generally be divided into two major groups. The first group is those patients that we see who are pre-menopausal. The second group are those patient’s who develop breast cancer post-menopausal or after the change in life. In general, breast cancer in these two groups of patients, are two very different diseases. Breast cancer in pre-menopausal women tend to be much more aggressive, spread earlier and chances for survival tend to be lower stage for stage compared to women with post-menopausal disease. Women with breast cancer after they have gone through menopause tend to be slower growing and “better behaved”. Also, women with breast cancer after they have gone through menopause tend to be hormonally responsive. Hormonally responsive means that they have estrogen and progesterone receptors and may respond to anti-estrogen therapy, this is what some people call “estrogen fed tumors”.
The second thing that we look at is whether or not a woman’s lymph nodes are positive. In all the studies that have been done in breast cancer, the number one factor that best predicts which women are at risk for their breast cancer coming back is whether or not their lymph nodes are positive. This is why we sample lymph nodes. The removal of lymph nodes from under the arm doesn’t necessarily help in the overall treatment of a woman’s breast cancer. However, the information that we gain from the removal of the lymph nodes is extremely important in determining what therapy is necessary. Patient’s with lymph nodes that have disease involvement have a much higher risk of reoccurrence of thier breast cancer. This is why the chances of needing chemotherapy is much greater in patients with lymph node positive disease.
The next thing that we look at on the path report is the size of the tumor. The larger the tumor is the greater the risk of reoccurrence. This seems to be most prominent when tumors reach 3-4 centimeters and larger.
We are interested in the grade of the tumor which roughly tells us how fast the tumor is growing. The other molecular studies, such as estrogen and progesterone receptors, Ki- 67, HER-2/neu status are also important in determining a patient’s overall prognosis.
After reviewing the patient’s pathology, we can then determine the stage of a tumor. Staging is important in most cancers; a patient’s stage is usually categorized as stage 1, stage 2, stage 3 or stage 4. Stage 1 disease is the earliest, in breast cancer this means the disease is confined to the breast. Stage 2 disease includes larger tumors and women with a few numbers of lymph nodes positive. Stage 3 is what we call locally advanced disease, with very large tumors or multiple lymph nodes positive. Stage 4 disease is when breast cancer spreads beyond the breast and lymph nodes to involve other organs in the body, such as bone, brain, liver, lung, etc. All these factors go in to us determining what treatment a woman would need.
The breast cancer patient that I saw was a young lady who was pre-menopausal, she had multiple lymph nodes positive, and her tumor was estrogen progesterone receptor positive. She will require chemotherapy, followed by radiation therapy and then will be placed on anti-estrogen therapy. With these therapies her chances are good.
God bless nurses
I’m always constantly amazed at people’s ability to care for other people. I think that nurses are some of the most unappreciated and some of the most overlooked heroes of our society. Nurses and what they do really are the glue that keeps our healthcare system together. A good nurse and a caring nurse probably has more impact on patients than a physician has. Oncology nurses, in particular, tend to be people who give so much of themselves to their patients. Whether it’s easing a patient’s fear, being a patient advocate or having the skills to deliver therapy in a safe and effective manner, they make the lives of our cancer patients much better. I think the bottom line is that behind every patient that recovers from their cancer is a good nurse.
Another group of nurses that I would like to talk about are the nurse practitioners. One of the greatest challenges that face oncology practice in the next 20 years is a projected short supply of oncologists. In general, the average age of oncologists is getting older. More and more are approaching retirement and there are fewer and fewer doctors that are being trained to go into this field. I believe that one way our country can help overcome this shortage is through the use of nurse practitioners. I’m a great advocate of nurse practitioners. These are typically extremely dedicated people, who in many cases have a great deal of experience. In my own practice I work every day with two nurse practitioners, both have years of nursing and oncology experience. They bring a unique and important perspective to the care of my patient’s. They are able to discuss with a patient different problems that patient’s may find difficult to speak to a male physician. Many of these issues are things that adversely affect a cancer patient’s life. They are efficient at controlling symptoms such as nausea, vomiting, and working with patients with fatigue. They bring a wonderful and dynamic aspect to my patient’s care. Nurse practitioners work in most states under what is called a collaborative practice agreement with a physician. This means that they are supervised and the care they render is ultimately the responsibility of the collaborative physician. This system of expanding an oncologist’s ability to follow up on patients and to address the needs of patients is likely the only way that we are going to meet the needs of oncology patients in the future.
Bad breaks
I’ve been working with a patient at the hospital who seems to have had the worst breaks in terms of his health as one can have. He’s a young man who seven years ago was a healthy, vibrant, super athletic man who subsequently developed acute renal failure. He underwent a failed renal transplant and has been on dialysis for the last seven years. Despite all the difficulty that is life on dialysis, he managed to get the majority of his strength back, and until recently, was exercising, lifting weights, and running every day. The patient now has just been diagnosed with the possibility of having multiple myeloma. Multiple myeloma is a relatively rare blood cancer that involves a particular type of immune cell; this cell is called a plasma cell. Plasma cells are an important part of our immune system, and when they become malignant they produce an excessive amount of protein that causes significant complications. These abnormal proteins can damage the kidney, can cause the blood to become too thick, and they can cause damage to the nerves. The myeloma cells primarily reside within the bone marrow, and can cause destruction of the bone causing high blood calcium which can lead to fatigue and mental confusion. They also can weaken the bone causing fractures. A patient with multiple myeloma who has complete kidney failure will be an extremely difficult patient to treat.
We have made a lot of advancements in the treatment of multiple myeloma. This was a disease that in the past we had a very limited number of medications that were effective. Over the last ten years, we have seen the development of multiple drugs; such as, Thalidomide, Revlimid, and Velcade. With these new drugs patients are certainly living longer, and with fewer side effects. Despite all these new drugs, the cure for multiple myeloma remains a very elusive thing.
One of the most gratifying aspects of my job is meeting people who approach their condition and their health issues as things that can be overcome. They see themselves as strong individuals who can fight and rally against whatever may come along. This patient in the hospital is a perfect example of one of these patients. Even though I know so much about cancer, I’ve often wondered how I would react if I were in the shoes of my patients. I hope I would show as much courage, dignity and class as some of the patient’s that I meet every day.
St. Patrick’s Day
Our sickest patients that we see as oncologists are in the hospital. As time has gone on & with the changes that have been made as to who can be hospitalized and who can’t be hospitalized, the number of patients in the hospital who are truly very ill has risen. Patients tend to come and go much quicker out of the hospital, and those patients’ left behind tend to be most sick & most seriously ill. In the hospital currently, we have a patient who is under going treatment for acute myelogenous leukemia. Working with leukemia patients’ is extremely challenging as a physician, a lot of hospitals don’t have the man power, the nursing expertise or the referral doctors to allow us to treat patient’s with leukemia. A typical stay for a patient newly diagnosed with leukemia is somewhere between six and eight weeks. They tend to get very sick as they go through chemotherapy, and then there is a long period of time when their blood counts are low & they are susceptible to infection. They tend to have significant nausea & vomiting and tend to get sores in their mouths. These things usually lead to a patient not being able to eat well & they wind up usually on some form of I.V. nutrition, which is “steak & eggs” through the veins. They almost all have some kind of infection when they first present because of the severe immunosuppression that leukemia cause.They require innumerable number of blood transfusions and platelet transfusions. It’s a sobering fact that out of all the patients that we start on treatment for leukemia probably as many as 20% of them die before they leave the hospital, just from the toxicity of the chemotherapy or the resulting low blood counts & their inability of the immune system to fight off infections.
The other types of patients that we now have in the hospital are those patient’s with advanced disease and having a significant amount of problems related to the disease. This includes bowel obstructions, pleural effusions, and significant pain. Trying to somehow relieve their symptoms or in many cases help them with tough choices regarding end of life issues and palliative care is a challenge. Although being in the hospital and seeing hospitalized patients is a nice contrast to working in the office, the week that we are on call is among the most taxing that we go through. I think a lot of the reason why it is so exhausting is trying to figure out what is best for a particular patient, and whether some particular complication or symptom can be controlled.
The other type of patient that we see in the hospital is newly diagnosed patients. Patient’s who come in to the hospital and are diagnosed with cancer are usually ill and are struggling with the new diagnosis. It’s sometimes difficult to come in and establish a relationship in a very short period of time with these newly diagnosed patient’s and set up a treatment course, get a patient to understand their treatment and then in some cases to proceed with treatment. To top it off, it’s raining today.
The most interesting patient of the day was a gentleman with metastatic thyroid cancer. This case is interesting because most people with thyroid cancer are cured of their disease either through surgery, or the use of radioactive iodine. The prognosis and chance for cure are very, very high. Unfortunately in this patient’s case, those therapies were not successful, and he is now struggling with disease that has spread to his lungs. His CAT scans looks like there are literally hundreds of marbles inside his lungs. There is very little in the way of drugs that have been shown to be effective in his kind of cancer. Several new drugs out on the market have shown some signs of activity in metastatic thyroid cancer. The patient was recently on Nexovar which is a new drug that is FDA approved in the treatment of renal cell carcinoma. The patient received it and had a few months of stabilization of his disease, unfortunately his most recent CAT scan showed progression of his disease. I have recently recommended that he go on Thalidomide, which is another drug that has been tried in many different types of cancer. It’s a drug that has a notorious past for causing birth defects in children in the 1960’s. We now use the drug as a means to blocking the tumor’s production of new blood vessels, thereby starving the tumor & hopefully keeping the tumor from growing or even dying. It is also a very expensive medication. His chances of responding to the Thalidomide are relatively small. He is a young man and wishes to continue to try to do everything he can at this point. The financial burden that he has had to bear while on these new oral medications have been quite severe, and he feels quite concerned & even guilty that much of his life savings and his retirement have been used up paying for these drugs. He worries about his wife and how she will be able to survive after he is gone.
This is an example of how the economics of cancer care is such a problem in the
On a more cheerful note, I had the pleasure of having a long-term patient that I haven’t seen in several years come back and see me. She is doing well and it was an absolute pleasure to see her. She is over 10 years out from her diagnosis and would be considered, to me, one of my miracle patients. Her disease was so aggressive and so advanced at presentation I though her chances of surviving were virtually zero. But after ten years she is healthy, well and caring for her grandchildren. Overall if I could have one of these patients on my list a day every day would be a good day.
I hate smoking
Today’s theme in my office was tobacco causes cancers. I saw three people with squamous cell carcinoma of the head and neck, all three had been long-term smokers, all were in various stages of treatment. Squamous cell carcinoma of the head and neck is one of the most difficult cancers to treat. It is also one of the most challenging for patients because of the side affects of the surgery, chemotherapy and radiation therapy that is used in this disease. These treatments are very disfiguring. Patients struggle a lot with the changes in body image. I also saw three people with lung cancer, all long-term smokers. I always tell my patients that if tobacco were illegal or no one smoked that a majority of us medical oncologists would be put out of business. I have always been a person who believes in personal liberty and the principles of our country of personal freedom, but over the years of my practice of oncology I have grown to hate cigarettes. To watch the devastation that cigarettes have caused in my patients has deepened my distain for tobacco and its past acceptance & it’s present day usage. I have cheered as communities in my area have passed smoking bans, and I believe that as a society, it is important that we do everything in our power to try to reduce smoking in our communities. I long for the day that I can no longer see patients with smoking related cancers; it would put me much closer to being able to say that cancer is a thing of the past.
/6/08
Day to catch my breath
Today was a day that I was actually slow in the office. Most days are days that I run behind & struggle to keep up. Today was one of those rare days that my list was light & I felt like I had plenty of time to spend with my patients, return phone calls to referring physicians, do some research on different treatment protocols & to actually do some journal reading, it was a really nice day.
I have a patient that has Non-Hodgkin’s lymphoma. The patient’s treatment course has not gone well, it has been interrupted by hospitalizations from toxicity from chemotherapy, and she has had treatment delays because of low blood counts. The treatment has been delayed because of evaluations at tertiary care facilities for possibility of a stem cell transplant. All these things have conspired to make her course a very rocky one. This patient has been a patient that has handled these ups & downs extremely well, however, today’s discussion turned to the possible need for radiation therapy. I’m constantly amazed at the fear that a lot of patient’s have about radiation therapy. This fear, although sometimes very justifiable, seems out of proportion to patient’s fear & concern to chemotherapy. As a medical oncologist, I feel deeply that we have to look at all tools at our disposal as gifts from God to be used absolutely in the best possible way to benefit our patients. This would include chemotherapy, radiation therapy, complementary medicine, even at times alternative medicine. I’ve learned early in my career that the mind and faith of a patient plays a bigger role in whether that patient gets well & how they will do than all the other factors that go into how the patient tolerates the therapy. A patient who truly fears any kind of therapy will ultimately do worse than a patient who is able to overcome their anxiety about the treatment. Patient’s should know that some degree of anxiety & fear associated with treatments that they have to go through as a cancer patient are justifiable & real. I think as an oncology community we do a poor job at adjusting the idea of fear in our patients. The idea of fear in our cancer patient’s, have fear in cancer itself, fear of the treatments that we are recommending to them, fear in altered body image, and the list goes on and on.
I spent a lot of time with my patient with lymphoma trying to relieve the fear of radiation therapy; ultimately I don’t think I was successful.
Tuesday 3/4/08
Tumor Conference
Today is our tumor conference. Tumor conferences are meetings held at a hospital that are attended by medical oncologists, radiation oncologists, surgeons, pathologists, & radiologists, where we sit down & discuss interesting cases. Tumor conferences are a great place for people involved in the care of cancer to stay abreast our Trans literature, it also represents a unique way in which patients can obtain second opinions regarding their case. There are other such conferences held by other hospitals & universities. Some hospitals have disease specific conferences such as breast conferences, or head & neck conferences. I think this is something that patients should be made more aware of and ask their oncologist if their case can be presented in these conferences. There have been numerous times in my years of practice that I’ve presented a case and have found additional information about the case that has ultimately changed how I treated the patient. This included in discovering a second type of cancer involved that was initially overlooked by the pathologist, I’ve found situations in which a patient’s stage has changed because of what was presented in conference and I have certainly had my overall treatment plan influenced by whatever oncologists & radiation oncologists have brought to the table in these conferences.
Today I am presenting a case of a patient with small-cell lung cancer, who presented with superior vena cava syndrome which is a situation in which the tumor in the middle of the patient’s chest blocks off the venous drainage from the upper part of the body & the upper part of the body swells. These are always challenging cases because of the urgency in which we need to begin treatment & the usually aggressive nature of the cancer that is being diagnosed.
