Dr. Robert Pluenneke : May 2008 Archives

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 United States to try to treat patients based on the best possible combination of medications. Making recommendations based on the most recent data available in the scientific literature. This is called evidence based medicine.  The NCCN and the American Society of Clinical Oncology have published practiced guidelines or “pathways”.  These pathways are made by the experts in a particular area of oncology. For example, breast cancer guidelines being drawn up by experts in the treatment of breast cancer.  The experts take the best available evidence and put it in a comprehensive pathway that recommends initial work up, diagnosis and then treatment of particular subtypes of cancers.  What angers me about tertiary care facilities, such as, MD Anderson, Mayo Clinic, and others is that many times patients return from these institutions given recommendations that fall outside these institutes own published guidelines.  It seems like these institutions believe that patients coming to see them want the newest, latest, greatest medicine even though the newest, latest, greatest combination of medicines may be unproven and have a higher risk of toxicity. There have been many times in oncology, where things that have seemed like a good idea, have become the standard of care, then only to have additional studies ultimately show these therapies to be no better, if not worse, than this standard of care.  Examples of this are stem cell transplant in breast cancer, the drug Iressa, and most recently Procrit like drugs where data suggests that use of these drugs may, in fact, increase mortality.

 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 China, Europe and, all over the United States.  She has lived to see her grandchildren graduate from college and is very active in charity work throughout her community. 

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.

The American Society of Clinical Oncology meetings are this month in Chicago.  Once a year the society brings together oncologists from all over the world for a five day meeting dedicated to the most recent research. It is a meeting as an oncologist I try to make every year.  I always come back from the meeting excited and hopeful about the future of my oncology patients. It also is an amazing conference where you see just how many people in this world are really working every day to fight cancer.  Usually there are over 30,000 people that attend the convention and conference.  It is always interesting to go to the educational part of the conference. This is one of the ways, in my own practice, that I try to keep up to date.  So much in oncology is moving so fast that without reading and studying every day you can lose your edge pretty quickly.  This conference allows oncologists to cram their mind with as much information in 4-5 days.  Listening to the presentations of some of the advanced research and clinical trials that are being done around the world again marks the idea that little by little, we are winning the war against cancer. 

It is also an opportunity to re-establish relationships with oncologists from different parts of the country and the world. I look forward to seeing physicians who I have trained with from around the country. One of the frustrating things about the conference is that you can’t go to every thing. Usually what I pick in terms of lectures and conferences that I attend depends on what patients I have been seeing most recently.  This year I will spend most of my time going to breast cancer conferences, multiple myeloma conferences and also lung cancer conferences. I know there will be things that I will miss.  By going to this conference and other conferences throughout the year I feel that I am able to continue to treat my patients with the most up to date and the most current therapies possible.  It also reminds me that we are truly making progress and puts a little bit of “hop” in my step.

In medical oncology today there are lots of different ways in which to stay up to date.  There are computer services, there are medical journals, and there are educational conferences that are given regularly.  It is so important that oncologists spend as much time as possible staying current.  The progress and the changes in oncology come so frequently. This is a one of the challenges of being an oncologist today.  I think as oncology patients, when you’re first diagnosed with cancer or are getting a second opinion, it would be a reasonable question to ask an oncologist on how they stay up to date.

I read an article today about proton beam machines being used in oncology.  These are fascinating machines.  Today in the United States, there are five proton beam centers that are being operated, and there are between 5 and 15 that are either being built or being planned.  Proton beam is a unique way of treating cancer. It is very focused and is able to kill a tumor with very little damage to the surrounding tissues.  Proton beam has been used most commonly in prostate cancer where over 8,000 patients have been treated. It has also been used in difficult tumors at the base of the brain and some other pediatric tumors.  The benefit again for proton beam is that the beam of energy used is so focused purely on the tumor that patients have virtually no side effects and no long term complications.  This is in contrast to standard radiation therapy that is used commonly today in oncology for many different diseases.  The problem with the proton beam is that the price tag for one of these machines is close to $200,000,000. You would have to treat lot of patients or charge a lot of money for each treatment to make a center that costs $200,000,000 profitable. This is an example of one of the difficult challenges that the United States faces in dealing with its healthcare system.  Almost every therapy can be made a little bit better. Every device can be made a little bit more efficient. Pacemakers can last 20 years instead of 10 years, robotic machines that perform surgeries can be improved, and most times outcomes can be improved.  Unfortunately, all these improvements put additional stress on the healthcare system by making it more and more expensive. At what point is the therapy good enough?  Interestingly, there have been no randomized controlled trials evaluating proton beam therapy versus other radiation therapy. Without this research we won’t be ale to tell whether the benefits of proton beam therapy will justify its astronomical cost.  To be honest, If I ever get prostate cancer I will want proton beam therapy……..