June 2008 Archives

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 Chicago.   It was a great meeting. Like these meetings usually do, it renewed my faith that we are actually making progress in the fight against cancer.  It also confirmed the global reach of cancer & the global crusade against cancer.  I was able to listen to physicians who practice in Britain, Austria, Italy, Australia, and New Zealand all present important study results in the various sessions that I attended.  My only regret is that there weren’t 2 or 3 of me so that I could get to every meeting that interested me.  As I listened to these speakers from around the world, it re-energized me to try to be aggressive in recruiting patients for clinical trials. It’s through these important clinical trials that we are making the progress against cancer.  A researcher from Austria presented a clinical trial looking at young women, before the age of menopause that had developed early stage breast cancer.  In this particular trial, there was a 98% 5 year survival rate, this is an amazing statistic for this disease. The day after I got back I saw a new patient that was very similar to the patients treated on this trial. The information I learned helped me make recommendations to her about the treatment she needed.

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 Japan, China, Brazil, Argentina, Mexico, Asia, India and many European countries, also South Africa and other countries in Africa.  As you walked through the conference center and heard the tremendous number of people speaking a foreign language, it truly made you feel that our world community is much smaller than I think anyone really realizes. The fight against cancer is a universal one. Physicians all over the world see patients just like me, fighting the battle against their cancer. It helps me to know that I am certainly not alone….

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.