MedWorm: Oncologists

What's Sauce for the Goose May Not Be Sauce for the Gander

Doctor David's Blog — Thu, 26 Jan 2012 02:36:00 +0100

Avastin has been in the news a lot lately, and most of the press has been negative. In November, the FDA revoked its approval of Avastin to treat newly diagnosed metastatic breast cancer. Then, in December, Genentech, who manufactures Avastin, announced it would not seek FDA approval for the treatment of ovarian cancer, based on studies showing an improvement in progression-free survival but not overall survival. Of course, whether Avastin helps women with ovarian cancer remains a controversial question, depending how you value progression-free survival. Compare this report with this one, for example. In tomorrow's New England Journal of Medicine, there are two reports of clinical trials evaluating Avastin for patients with newly diagnosed HER2-negative breast can...

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Yes, we have no...Zofran?

Doctor David's Blog — Mon, 23 Jan 2012 02:47:00 +0100

This article, published in the scientific journal Nature in October, discusses the effect of drug shortages on clinical trial enrollment. Closer to home, the clinical trial I am running looking at Doxil and temsirolimus for sarcoma patients is on hold because Doxil is unavailable. We haven't enrolled a new patient in months, and there is no end to the shortage in sight. Photo Credit The shortages are not limited to chemotherapy drugs (which, of course, is evidence that the problem is not due to the inability of oncologists to make a profit giving drugs to patients). Drugs for ADHD, the components for iv nutrition, anesthetics, and many others are affected. In fact, on Friday I was told our hospital has only a 5 day supply of Zofran, the mainstay anti-nausea drug us...

Entering the Fray

Doctor David's Blog — Fri, 13 Jan 2012 23:38:00 +0100

The vast majority of biomedical research conducted in the United States is funded by taxpayers through grants distributed by the National Institutes of Health. This includes investigator-initiated laboratory research (the work we do in our labs) as well as clinical trials, both large and small (NIH is a large supporter, for example, of the Children's Oncology Group). In the not-too-distant past, the results of all of this research were published in scientific journals which were available to anyone who could gain entrance to a medical library. With the rise of the internet, journals began publishing online, and charging a fee for viewing these articles on their websites. Those of us who work at academic centers generally have free access to most (but not all) of the...

2012

CancerDoc — Thu, 12 Jan 2012 20:15:00 +0100

The last couple years were pretty difficult. Personal problems, professional problems, existential problems.But, rather than view 2012 as some kind of "new" year, I'm starting to accept that all pain is simply the flip side of happiness. As I see countless cancer patients struggle with their lives and deaths, I start to see it all as the grand cosmic cycle of life and death, birth and creation.Ecclesiastes. The Tao. Samsara. We are all just cycling through, brief ripples on the cosmic ocean of life.I have tried so hard over the years to insulate myself from pain. Exercising, studying, saving money, trimming negativity from my life, cultivating spirituality and on and on.Yet, no matter how much free range, grassfed, fair trade, organic, local food I eat... no matter how caloric restricted m...

It’s time to stop getting that PSA test for prostate cancer

Dr.Kattlove's Cancer Blog — Tue, 10 Jan 2012 19:37:00 +0100

I was reminded of this when I learned of a new article “hot off the press”, published in the Journal of the National Cancer Institute. The news was so exciting that they published the results online before the journal was released. And what was so exciting? We learned that screening for prostate cancer doesn’t save any lives.The study described in the article was the Prostate, Lung, Colorectal, and Ovarian Screening trial (PLCO). I already wrote about the Lung cancer part of the trial (CT scanning), which worked; CT scanning saved lives. But the Prostate cancer trial (PSA testing and rectal exam) did not.Here is how the trial was done. Men were randomly assigned to either screening with yearly PSA testing (Prostate Specific Antigen – found in the blood and goes up if there is prost...

"We need a better test"... or do we?

Doctor David's Blog — Tue, 10 Jan 2012 19:26:00 +0100

This study made headlines, in large part because it runs contrary to conventional wisdom -- that cancer screening tests, by detecting the disease at an early stage, save lives. A number of things struck me about this study and the way it was reported. This is one of several relatively recent studies that has called into question the premise behind cancer screening tests. Two years ago, I had a post about a revision of the US Preventive Services Task Force's position on Pap smears and mammograms. In that post, I talked more about how screening tests might be applied to particular patient populations. But cervical cancer and breast cancer are very different from prostate cancer. Women rarely die WITH breast cancer... they die OF breast cancer. In co...

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Don’t believe the headlines about Avastin

Dr.Kattlove's Cancer Blog — Sun, 01 Jan 2012 18:33:00 +0100

This study was mainly done in Europe and had the same results. The cancer took a little more time to progress in the women given Avastin, but after 3 years, the groups had equal numbers of deaths.What does all this mean? It means that blocking blood vessels with a drug like Avastin, though a great concept, isn’t the answer to ovarian cancer or most other cancers, unless there is a better blocker out there somewhere.I have always said that the main treatment for cancer is surgery. All the other treatments like chemotherapy and radiation make much less difference than does surgery – cutting it all out. Ovarian cancer, as well as most other cancers, is curable if caught early. Perhaps we need to spend out money on learning how to catch, not treat. (Source: Dr.Kattlove's Cancer Blog)

My name is FDA, and I approve of this message

Doctor David's Blog — Thu, 29 Dec 2011 18:10:00 +0100

As the new year begins and election season accelerates, we will be hearing phrases like that more and more. In the context of a political commercial, it is often pretty clear what is being approved and the basis for the approval. But what about new drugs? How does the FDA decide whether or not to approve a new cancer drug, and what exactly is being approved? In the era of targeted therapies, which are incredibly expensive to develop, and therefore incredibly expensive for patients and their insurance companies, these are crucial questions. Photo Credit I think the case of bevacizumab (Avastin) is a perfect example. Avastin was the first of a new class of drugs that treats cancer not by directly killing tumor cells, but instead by attacking the blood vessels that f...

Managing Pain

Doctor David's Blog — Sat, 24 Dec 2011 17:01:00 +0100

Pain. Little scares a new oncology patient as much as the idea of pain. Unfortunately, pain permeates my practice. Often, pain is the initial symptom that leads to a new cancer diagnosis. Cancer patients undergo frequent painful procedures -- biopsies, bone marrow aspirates, surgeries ... even a simple blood draw involves a small amount of pain. Because of this, managing pain is something I have some experience doing. So I was surprised when I read this article in The Washington Post this morning and discovered that "some [pain doctors] began decrying the increasingly widespread use of opioids and questioned whether the drugs worked." Really? There are pain doctors who question whether opiates (morphine, for example) work? Over the years, I have seen ...

Cancer Love

CancerDoc — Tue, 13 Dec 2011 08:49:00 +0100

L.D. was one of those patients that I sometimes get a crush on. Not in a teenage, pimply, excited kinda crush, but a chemotherapy, bald-person, gaunt, I-wonder-why-that-person-has-such-equanimity kinda crush.Like, how is a 49 year old single female chiropractor with metastatic colon cancer and liver and omental metastases so cheerful coming into the clinic? So appropriate and mentally balanced despite being totally shafted by nature, biology, God and country?Why does she smile and laugh after vomiting? Or pull clumps of hair cheerfully out of her scalp? Or gently respond patiently that she drove here alone for the umpteenth time? Or that she might check out acupuncture or Reike or craniofacial therapy or any host of things that are really cool, except if you have a f.ing bowel obstruction....

Phoenix Rising

CancerDoc — Tue, 13 Dec 2011 07:42:00 +0100

There is something about insomnia that makes one want to express thoughts for anyone on Earth to read. Banal, predictable, but personal and sometimes pithy thoughts.I've passed nearly the 6 (or is it 7) year mark in practice. G-d, it's hard to believe.What are some of the highlights?Engagement brokenLawsuitCynicism and Depression (they need capital letters)Failed romanceNearly quitting my practice out of burnout/ethical disgust/boredom/emotional impairmentHating my jobSelling the practice and becoming financially secureBuying a lot of crapGiving said crap awayBuying more crapTaking a lot of tripsFeeling the escapism of said tripsTherapyMore therapyKung FuYogaMeditationFriendshipsParents divorce sagaParents individual healingLots of vacations with same parents (individually)Broken relations...

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The world’s third most deadly cancer is becoming a greater problem here.

Dr.Kattlove's Cancer Blog — Thu, 08 Dec 2011 22:48:00 +0100

Every year, about 700,000 people die of liver cancer. I am referring to cancers that start in the liver, not those that have spread there. Spread to the liver is a very common problem in patients with cancer. But, in my practice, I rarely saw cancers that started in the liver. That may change for newer generations of American oncologists.Most liver cancer is found in developing countries, particularly in Asia. Half of all cases are diagnosed in China where the rate of liver cancer is about 5 times that in the U.S. Most of the liver cancers in China are caused by infection with hepatitis B virus. But this should become less of a problem in the future. We now have a vaccine to protect against infection with this virus and the number of liver cancers caused by this virus will drop.In the U.S....

Breast radiation after cancer – I was wrong

Dr.Kattlove's Cancer Blog — Mon, 21 Nov 2011 01:28:00 +0100

Often in my practice, women would ask after their lumpectomy for breast cancer if they really needed the proscribed radiation therapy. I always said yes. It would lower the chances of the cancer returning in that breast. But, I didn’t think it was life-saving. So I wouldn’t worry if older women wanted to opt out. The radiation was a lot of trouble. Daily visits over the course of 6 or 7 weeks was a major effort for them. And, after all, their tamoxifen should lower their chance of a recurrence.I was wrong. This week (Nov 12) in the British journal Lancet, a group of researchers from Oxford analyzed all the work ever done on the benefit of radiation therapy to the breast after lumpectomy. They found that not only does it lower the chance of recurrence in the breast, it also lowers the w...

Colonoscopy isn’t perfect.

Dr.Kattlove's Cancer Blog — Thu, 20 Oct 2011 22:08:00 +0100

I think of this when I see our friend Sarah. About five years ago her husband died of colon cancer even though he had a “negative” colonoscopy two years before. Everyone blamed the poor doc who did the procedure, but it turns out that he might not have been at fault. Colonoscopy reduces the chance of dying from this cancer, but doesn’t entirely eliminate it.I was reminded of this by a recent report in the Journal of Clinical Oncology. The study, done in Germany, found that the chances of developing colon cancer within ten years of a negative colonoscopy were about one-fourth to one-third that of people who didn’t have the procedure. That is good, but not great. Another study, this time from Canada, (Annals of Internal Medicine, January, 2009) came up with similar results. Only this...

You are never too old for chemotherapy

Dr.Kattlove's Cancer Blog — Fri, 07 Oct 2011 23:28:00 +0100

One of the mysteries of my practice was that I could never predict how well or poorly a patient would tolerate chemotherapy. My bias was that the older a patient was, the less well he or she would be able to take the stuff. Not true. Often my oldest patients would float right through their treatment while younger ones suffered major side effects. I couldn’t explain it except perhaps that having lived a long life exposed these older folk to adversity, which made them better able to tolerate their treatment.But, there was little written information that confirmed my experience. Most studies of chemotherapy excluded older patients, even though over half of all people with cancer are over 65. But now studies of the elderly are being done. Recently two reports have appeared that focused speci...

Tamoxifen or Aromatase Inhibitors or both for early breast cancer?

Dr.Kattlove's Cancer Blog — Thu, 15 Sep 2011 18:01:00 +0100

Perhaps the greatest drug ever developed for the treatment of cancer is tamoxifen. Since it was introduced about 30 years ago, it has probably saved hundreds of thousands of lives. Its main use has been in the adjuvant setting to prevent recurrence. Early on it was used to treat cancer that had become widespread, but now it is used less because most women have had the drug before the disease spread; in these instances it didn’t prevent the spread. It has been known for decades that breast cancer in many women was sensitive to hormone treatment. Removing the ovaries in younger women could cause the cancer to melt away. Likewise, high doses of estrogen could produce the same effect in older women. Eventually tamoxifen was synthesized. This is a chemical that looks like estrogen and interac...

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More is not better – at least in treating breast cancer.

Dr.Kattlove's Cancer Blog — Wed, 07 Sep 2011 18:24:00 +0100

When chemotherapy first appeared on the scene as a major treatment for cancer, there were many studies in animals that showed that higher doses of drug were more effective. Higher doses led to more cures – at least in rats! But, unfortunately humans aren’t as tolerant as these little uncomplaining animals and if a few extra rats died because of the high doses, no one mourned.But women with breast cancer can be tough and many willingly accept high doses of chemotherapy if it promises them a longer life span or even a cure. They often want to see their kids graduate, get married, have children. No surprise then, that thousands would accept treatment with high doses of chemotherapy.This treatment is called high dose chemotherapy with autologous stem cell support. In the 1980s and 1990s, i...

Maybe Barrett’s esophagus isn’t such a terrible thing

Dr.Kattlove's Cancer Blog — Thu, 21 Jul 2011 18:48:00 +0100

A few weeks ago, I attended a wedding and sat next to a man who told me all about his issues with Barrett’s esophagus. Barrett’s esophagus, which can lead to cancer is a change in the lining cells of the lower esophagus. It is usually caused by constant acid reflux from the stomach. He was getting frequent endoscopies, which means that his doctor was looking down his throat at his esophagus to make sure he didn’t develop a cancer in his esophagus. As you may know (and I have written about this) cancer of the esophagus is a terrible disease. It is generally incurable and kills people by starving them. That is why he was getting these procedures. Hopefully if a cancer does arise and is detected early, he may be curable.He had been dealing with gastric acid reflux into his esophagus (he...

Maybe it is time to reconsider screening for lung cancer

Dr.Kattlove's Cancer Blog — Fri, 15 Jul 2011 20:40:00 +0100

I never thought it would be worthwhile. I had a neighbor once who had a small lung cancer found on a routine chest x-ray It was removed and he never had a problem with the disease again. Maybe his life was saved. But, many year ago, the Mayo Clinic did a study where they performed chest x-rays on a large number of smokers and found a lot of small cancers that were removed. But when they compared the number of deaths from lung cancer in this group with a similar group of smokers who didn’t get chest x-rays, there was no difference. They hadn’t saved any lives with their chest x-rays.The explanation for this is that many lung cancers probably start and then stop and go away; the bad ones that don’t go away are killers and catching them early, I thought, might not do much good. And lung...

Special Kids

Doctor David's Blog — Sun, 26 Jun 2011 02:40:00 +0100

All of the kids I take care of are special. Is that cliche? Maybe so, but it's true. I truly have learned something from each and every one of them -- though not always what I thought I would learn. Some kids stand out. My first "real" patient, who was 13 at the time, and is now, at the advanced age of 27, joining the military. The patient who got a transplant for her horrible leukemia... who was so sick going into her transplant that I said to her during her "consent conference"... "Well, if your kidneys fail during the transplant, at least your donor can give you one of his, too, and since your immune system will be his, you won't have to worry about rejection." Not only did her kidneys not fail, but she is alive, well, in remission, and sometimes takes her hor...

The cancer called “unknown”

Dr.Kattlove's Cancer Blog — Wed, 15 Jun 2011 17:39:00 +0100

Every so often – maybe once a year – I would see a patient who had widespread cancer yet I had no clue about where the cancer started. In spite of CT scans and other tests, I would come up empty handed. No obvious source was found. These cancers would be called cancers of unknown primary.Because these cancers were widespread, they were mainly incurable although there were some exceptions. In spite of their poor outlook, they might be helped by some kind of drug treatment like chemotherapy. But, I needed to know which drugs would be most effective and this depended on the kind of cancer it was. My first step would be to take the biopsy specimen from one of the metastatic sites to the smartest pathologist I knew and ask him to venture an educated guess. If it made sense, I would use that...

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Melanoma – maybe some progress

Dr.Kattlove's Cancer Blog — Fri, 10 Jun 2011 17:11:00 +0100

In this study, patients were given a drug that would boost their T cells, an important part of the immune system. We know that there have been occasional patients with widespread melanoma whose cancer disappeared spontaneously. Doctors think that this may be due to activation of the immune system and the patent rejecting their melanoma. Indeed trying to boost the immune system using a drug called interleukin-2 has been a useful attempt at treating melanoma with some patients experiencing very long-term remissions.But the new approach described in this study seemed to work, although the results were once again, not that spectacular. The good news is that all patients can be treated this way. But, the benefit was small. The drug extended patients’ lives by an average of two months compared...

Take exemestane (Aromasin) to prevent breast cancer? Not in my family

Dr.Kattlove's Cancer Blog — Tue, 07 Jun 2011 18:39:00 +0100

!Today’s newspapers are filled with reports of a new study that found the drug Aromasin could prevent breast cancer. I just read it and am not convinced. Aromasin is an aromatase inhibitor. This means that it blocks a woman’s ability to make estrogen (the main female hormone) if she has gone through menopause. It won’t block estrogen production from the ovaries, which is why it only works in post-menopausal ladies. It does this by blocking the enzyme aromatase that makes estrogens in a woman’s fat cells. I’m not sure we know why these fat cells make estrogens, but because of this, a post menopausal women will make about 10 percent of the estrogen she used to make before she went through menopause. This means, of course that fat women will make more estrogen and skinny women, less...

Myelodysplasia: Is it cancer?

Dr.Kattlove's Cancer Blog — Fri, 03 Jun 2011 23:12:00 +0100

One of the major and most devastating disappointments in my practice was to see patients who were cured of their cancer – usually lymphoma – who would then develop this devastating and largely untreatable disease. What is myelodysplasia? It is a disease of the bone marrow cells where they become dysfunctional. The early stem cells don’t make enough red cell, white cells and platelets. When I would look at the bone marrow cells, I would see enough of these early cells. They would just look peculiar. They would be misshapen or too big or the nuclei of the cells would be too big. How does this happen? We think is results from abnormalities of the genes. I would see it in patients who have had lots of serious chemotherapy along with radiation therapy. Certain drugs were particularly good...

Have cancer? Tired all the time? You are not alone.

Dr.Kattlove's Cancer Blog — Sat, 28 May 2011 18:57:00 +0100

Other than pain, nothing else would bother my patients as much as fatigue. Sure, chemotherapy and radiation took the starch out of them, but even without treatment at least half of people with cancer will be tired all the time. They feel better in the morning, but as the day wears down, so do the patients. Of course chemotherapy or radiation therapy add to the fatigue, and, even if these treatments are curative, many people will continue to complain of fatigue. I remember a young man with Hodgkin disease who even after many years, never got over it, even though he was cured. One study found that after, 5 years one-third of patients still felt washed out.All this was discussed in an recent article published in the Annals of Oncology (22: 1273–1279, 2011). After discussing the problem, the...

More options for pancreatic cancer

Dr.Kattlove's Cancer Blog — Thu, 19 May 2011 22:40:00 +0100

Many years ago I was consulted by a psychiatrist in his late 60’s who had pancreatic cancer. The cancer was inoperable, but he felt well. My advice – don’t take chemotherapy. The only drug we had then for treating pancreatic cancer was 5-fluorouracil (5-FU) and it was useless for treating this disease. I told him he would have more bad effects than good ones. He didn’t listen and went to another oncologist who provided his chemotherapy.Now I would advise him differently. New drugs have come along that can improve the outcome, although pancreatic cancer remains, with rare exceptions, a fatal disease. About 15 years ago, a new drug, called gemcitabine came along and in well-controlled trials, proved better than no treatment in improving survival and quality of life. And few side effe...

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Metformin – can it prevent cancer?

Dr.Kattlove's Cancer Blog — Thu, 14 Apr 2011 15:51:00 +0100

The other day, my friend Bill showed me an article in a magazine called “Life Extension” that touted the benefits of the anti-diabetic drug metformin (also known as Glucophage) in preventing cancer. Naturally I was skeptical. The magazine also promotes (and markets) vitamins, nutritional supplements, anti-aging treatments and all sorts of stuff to prevent disease. But Bill is a smart guy, not easily fooled. So I read the article and more importantly, looked at its sources. To my surprise, the article referenced lots of high-class articles in real scientific journals. Metformin turns out to be a hot item!I started reading and this is what I learned. Almost all the evidence for cancer prevention by this drug comes from studies of people with diabetes. Now diabetics are known to have high...

Another Kind of Tears

Doctor David's Blog — Thu, 10 Mar 2011 03:14:00 +0100

Photo Credit Tears are a fact of life in my business. Parents cry when I tell them their child has cancer. Children cry when they undergo painful procedures. We all cry when a child dies. But sometimes the tears are tears of joy. Jade came to my clinic for another opinion. She has a benign tumor, but it's in a bad place. As I have shared before, sometimes it isn't better to have a "benign" tumor. In order to remove Jade's tumor, she would need disfiguring surgery. She and her father were told there was no choice. Thankfully, they were told wrong. Even though Jade's tumor is benign, it can be treated with chemotherapy. It's a small tumor, and it's not causing her any symptoms right now. Even if we can't make it go away, if we ...

The Emperor's New Book

Doctor David's Blog — Wed, 23 Feb 2011 04:44:00 +0100

It may not be a new book anymore, and I actually read it a few months ago, but I would like to share my thoughts on Siddhartha Mukherjee’s The Emperor of All Maladies. Dr. Mukherjee subtitled his book, “A Biography of Cancer.” Much has been made in other reviews about the significance of this subtitle, and what it means to the approach he took to his topic – the history of cancer therapy. I am fascinated by the history of medicine. When I teach residents about current sarcoma therapy, I always teach them the history of how we got to where we are. Dr. Mukherjee took this approach to its logical extreme, beginning with the first known record of the disease in ancient Egypt all the way to the present. The main theme coursing its way through the book is the evo...

Keep those lymph nodes, ladies.

Dr.Kattlove's Cancer Blog — Fri, 18 Feb 2011 23:28:00 +0100

Ever since her breast cancer surgery our friend Gwen has had some swelling of her right arm. That is the side where the cancer was found and where her surgeon removed the lymph nodes from under that arm. This swelling of the arm, called lymphedema, happens often when those lymph nodes are taken. The lymphatic system, which gets disrupted in this surgery, plays an important role in channeling fluid from our arms as well as other parts of the body.Now a new study finds that Gwen cold have done without this surgery. To understand why lymph nodes are taken, we have to understand the history of breast cancer surgery. Around the beginning of the 20th century, breast cancer surgery was developed by William Halstead, a surgeon from Johns Hopkins. At that time, women were seeking treatment only whe...

Why Study Rare Diseases?

Doctor David's Blog — Fri, 18 Feb 2011 03:23:00 +0100

This article states that there are only 250 known people with Laron Syndrome worldwide. Photo Credit So why study such a rare disorder? Well, interestingly, people with Laron Syndrome don’t get cancer (they also don’t get diabetes, but this is a blog about cancer, so we’ll focus on that). This interesting observation raises a really obvious question: Why not? At first blush, there could be a very simplistic answer: IGF-1 makes your body grow. For you to grow from the size of an infant to the size of an adult, your cells have to divide many, many times. Each time a cell divides, it risks developing a mutation, and the accumulation of mutations leads to cancer. If you don’t grow any larger than a 7-year old, there are fewer cell divisions.&n...

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Should we take aspirin to lower our chances of dying of cancer?

Dr.Kattlove's Cancer Blog — Fri, 28 Jan 2011 00:17:00 +0100

Maybe. I used to think this wasn’t a good idea in spite of the suggestions in the literature that aspirin lowers your risk of colon cancer. Aspirin can cause bleeding. This can be from the intestine or even (rarely) into the brain. And, since the cancers prevented were colon cancers and I would still get my colostomy to catch it early, so why take the chance?Now a paper has been published in the January 1 issue of the British journal, The Lancet that is making me reconsider. There have been lots of randomized trials testing the effects of aspirin, mainly to prevent heart attacks and strokes. Aspirin prevents little cells in the blood called platelets from sticking together and plugging blood vessels. Most of these studies found that aspirin lowers the risk of heart attacks and strokes in...

More bad news for overweight women with breast cancer.

Dr.Kattlove's Cancer Blog — Fri, 31 Dec 2010 23:45:00 +0100

This time, the women are Danish. Perhaps too many of those pastries. One of the nice things about the Scandinavian heath systems is that in addition to covering all their citizens, they have terrific records. This week’s Journal of Clinical Oncology (Jan 1, 2011) carries a report from Denmark on the relationship between obesity and death from recurrent breast cancer.The researchers examined the records of 53,000 women who were diagnosed with early stage breast cancer. Because many of the women received chemotherapy, their weight and height were recorded. Chemotherapy is dosed according to these two numbers by converting them into a figure called the BMI (Body Mass Index), which is also our standard measure of obesity. A BMI of 20-25 (for example, 5’4” and 130 lbs.) is OK, 25-30 (5’...

How docs make money

Dr.Kattlove's Cancer Blog — Fri, 24 Dec 2010 19:09:00 +0100

One of the biggest disappointments in my career came during a course in medical economics at the UCLA School of Public Health. In that course, the professor was able to prove unequivocally that if a new procedure is introduced that provides money to doctors, they will use that procedure. Not to say doctors are any different from other people. That is just the issue. They are the same. Forget about altruism. Forget about wanting to help people. Sure, that is there, but making money seems to take over. Conversely, if a procedure is no longer profitable, suddenly its use will drop. This phenomenon was well demonstrated in a study just published in the December 15 issue of the Journal of the National Cancer Institute. The study involved the use of injectable drugs that slow the growth of prost...

David's First Book Review: The Immortal Life of Henrietta Lacks

Doctor David's Blog — Tue, 21 Dec 2010 03:14:00 +0100

I've discovered reading again. Or maybe what I've done is made a conscious decision to set aside time to read. Some books I've recently read have nothing to do with cancer, like Cloud Atlas. Then there's The Immortal Life of Henrietta Lacks. Rebecca Skloot did a marvelous job telling the story of Henrietta Lacks, a woman from Baltimore whose cervical cancer cells became the very first immortalized cell line. I think this book is a "must read" for anyone engaged in cancer research, if for no other reason than it reminds us that every cell line we work with was once a tumor growing in an individual... a person who had a family and friends, a person who suffered and probably died of cancer. Each of these people has a story, and knowing that story can inspire us...

What is Life?

Doctor David's Blog — Fri, 03 Dec 2010 04:47:00 +0100

Life is hard to define. Perhaps former Supreme Court Justice Potter Stewart summed it up best (though he was referring to hard-core pornography, not living organisms) when he said, "I shall not today attempt further to define [it]... and perhaps I could never succeed in intelligibly doing so. But I know it when I see it." Erwin Schrodinger gave a series of lectures in 1943 that were published under the title "What is Life?" NASA has an Astrobiology group that is charged with searching for evidence that there is life on other planets. Key to that mission is understanding what life is. How else would they know what to look for? Up until today, living organisms were thought to require four elements: oxygen, carbon, hydrogen, nitrogen, sulfur, and phosph...

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You're Kidding, Right?

Doctor David's Blog — Thu, 02 Dec 2010 03:58:00 +0100

(Another of David's rants about insurance companies) I've written many times about the absurdities I've encountered dealing with insurance companies. I've had another experience that I'd like to share. The patient came into clinic for chemotherapy. The PA examined him and heard an irregular heartbeat. Neither of us know the patient well, so we looked through his chart to see if anyone has ever noticed an irregular heartbeat before. No one had. We ordered an EKG, and it showed an abnormal rhythm. The patient has had several EKGs in the past, and this rhythm was a new finding. One possible explanation for the new abnormal rhythm would be if the patient's central line had moved a bit and was irritating the right ventricle of his heart. The be...

What is a good death?

Dr.Kattlove's Cancer Blog — Sat, 27 Nov 2010 22:22:00 +0100

Well of course, there probably is no such thing. Most of us want to live as long as we can. But when your fate is inevitable – like when you have far advanced cancer – maybe the important thing is being comfortable and being surrounded by loved ones. Unfortunately, if you are in the hands of American oncologists, particularly in academic medical centers, your chances of achieving this goal are slim.This is illustrated by a recent report from the folks at the Dartmouth Institute for Health Policy and Clinical Medicine. They like to examine patterns in medical care and in this instance looked at what kind of end-of-life care terminal patients were receiving. They used Medicare data, so the patients were generally over 65. They looked at 20% of all Medicare beneficiaries who died between ...

I never would have believed it.

Dr.Kattlove's Cancer Blog — Mon, 08 Nov 2010 00:07:00 +0100

It looks like CT scanning for lung cancer will save lives. The National Cancer Institute just stopped their trial of CT scanning of smokers and former smokers who had quit within the last 15 years. They stopped because the people getting the scans were 20 percent less likely to die of lung cancer. Good news. Saving lives is the gold standard of any cancer screening procedure. Forget about catching something early – we still don’t know if that will help. Saving lives is all that counts.The study was conducted very simply. Around 50,000 men and women who had been or were former heavy smokers and between 55 and 74 were recruited and divided into two groups. One group received spiral CT scans every year for a total of 3 years – these are fast scans that are said to give only a low dose o...

The new world of targeted therapy – where is it heading and how much can we afford?

Dr.Kattlove's Cancer Blog — Fri, 05 Nov 2010 00:02:00 +0100

We all know that most cancer therapy is like a nuclear weapon, killing everything in its wake. In the last 20 years, we have been moving away from this (although radiation and chemotherapy are still the major treatments) toward treatments that target specific molecules in the cancer cell.Perhaps the best example of this is the use of hormonal manipulation to treat breast cancer. Very early on in the history of treating this cancer, doctors learned that removing the ovaries of young women with advanced breast cancer could cause it to regress; giving high doses of estrogen to older women with breast cancer could also be successful. But not all women responded. Only later did we learn that in many women, but not all, breast cancer cells carry receptors for estrogen (and progesterone) that int...

It's Time To Hang It Up

CancerDoc — Thu, 28 Oct 2010 23:08:00 +0100

This is my last entry. This blog has served its useful purpose in my life. It's allowed me to explore many emotions and thoughts during this transition point in my life, from student to physician and maybe to the beginning of healer.But, it's a vanity in a way. A service to ego and it's time to face life without a crutch. Time to turn inwards as we still fight to grip with all that is outwards.I am grateful for the responses over the years. The many insights. The love. And, sometimes lack of love.Time to unplug and whip out the old pen and paper... (Source: CancerDoc)

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What can we do about ovarian cancer?

Dr.Kattlove's Cancer Blog — Fri, 22 Oct 2010 16:15:00 +0100

You don’t hear much about ovarian cancer, yet in 2010, nearly 22,000 women will be diagnosed with this cancer and nearly 14,000 women will die. It is a tough cancer to find early. Only 15 percent are found when it is still confined to the ovary. Because of this there have been many studies trying to pick it up before it has spread. None have succeeded, even though there are sophisticated ultrasound tests and even blood tests that can find the cancer. It is usually too late when these tests uncover the cancer. In fact, many experts have said the best early warning are clinical symptoms – like nausea and bloating. Try running to the doctor to look for ovarian cancer every time you have one of these.Treatment hasn’t gone far either. The usual approach is to remove the cancerous ovary al...

Stop those hormones ladies! They cause breast cancer.

Dr.Kattlove's Cancer Blog — Wed, 13 Oct 2010 23:22:00 +0100

The other day our friend Joan called me. She was getting really fatigued from her chemotherapy. She was getting the chemotherapy because she recently developed stage 2 breast cancer. Joan came to mind when I read an article in the Journal of the National Cancer Institute that discussed the relationship between post-menopausal hormone therapy and breast cancer. In 2002, a large study was published by the Woman’s Health Initiative that pointed out the risk of breast cancer in women who took hormones for their menopausal symptoms. Everyone had sort of suspected that these drugs increased the risk of breast cancer, but this study really proved it because it was a randomized trial. Half the women took hormones and half didn’t.The results showed that the rate of breast cancer in women taking...

Should I keep getting my PSA tested?

Dr.Kattlove's Cancer Blog — Fri, 08 Oct 2010 23:38:00 +0100

It will probably cause me more trouble than it is worth. I have a large prostate and because of this (partly at least) my PSA (prostate specific antigen, which goes up with prostate cancer) is higher than experts think it should be. Many urologists (surgeons who treat prostate cancer) think that anyone with a PSA greater than 4 should receive a prostate biopsy to look for cancer. Some urologists set this number even lower at 2.5.A few years ago, when my level bumped up to 6, my doctor recommended at biopsy. Luckily, it was negative and I have remained at around 6 without another go at this most unpleasant procedure. But quite a few men, who are screened yearly like me, aren’t so lucky. They are found to have cancer and get treated for cancer – with either radiation or surgery. Either t...

Grief

CancerDoc — Thu, 07 Oct 2010 16:35:00 +0100

Lunchtime. I don't each lunch, really. Maybe tea time. Or downtime. Or depressed time.This morning was a bear. The sounds of crying. Not ostentatious crying. Just sobbing. I'm sorry. There is nothing more I can do...I must say that to people ten times a week. Most of the time it's just a stunned silence, then a polite thank you.Every now and then, it's anger.Sometimes, histrionics.But, then there is just the solitude of grief. It doesn't matter how many family or friends are in the room. When the realization dawns on the patient that life is over, there is this retraction of space, this contraction of feeling. Alone, facing your death.This morning was one of those. I feel washed out. I have to gather myself for the afternoon panel of patients. (Source: CancerDoc)

Rare But Serious

Doctor David's Blog — Wed, 29 Sep 2010 14:58:00 +0100

The patient and her parents were hardly focused on what we were saying. Not surprising, since she was still recovering from the news that the pain in her leg was not from a sports injury, but from osteosarcoma. Kameron was a high school athlete, and now, instead of anticipating a college scholarship to play hockey, she was anticipating a year's worth of chemotherapy and a major leg surgery. She and her parents were in the office, listening (but probably not hearing) to the side effects she should expect from her upcoming chemotherapy. At the end of the conference we discussed some of the "rare but serious" side effects, like fertility loss and heart failure. Fertility loss is something that catches people's attention. To some extent, so does heart failure. ...

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Two Steps Forward...

CancerDoc — Fri, 17 Sep 2010 14:47:00 +0100

The "no consumption" thing is terrifically difficult. Coffee and other beverages are being phased out.My canvas bag travels with me to the fruit and vegetable aisle.Takeout, carryout, order out, etc. has been crushed.Books from Amazon have slowed to a trickle and will soon dry up.And yet, there is still a small amount of recycling that I had to put out this morning...I liken this attempt to my yoga practice. Or my meditation practice. Or my practice of medicine for that matter.You keep trying. Despite some injuries here, or boredom. A setback. A steak dinner. A piece of styrofoam.But, hopefully, with practice, you become the person you want to be. I was listening to an audiobook about Confucius and his philosophy. Like all religious teachers before and after, like the Buddha or Jesus, Conf...

The Fatman

CancerDoc — Tue, 14 Sep 2010 00:58:00 +0100

I don't know why I always think of this patient as the "Fatman".Well, other than the obvious fact that he is quite overweight, tipping over 300 lbs on a 5-10 frame.Maybe it's his lack of self-consciousness about it. His laughter and cheer and egolessness, if that is even a word.Which spellchecker tells me it isn't.A wonderful guy, a healer. A therapist. Not just any therapist, but an uber-therapist. Well regarded nationally, urbane, published, graceful, the Fatman is a mensch in every way, except in regards to himself.I first met him more than 3 years ago. He came to me ostensibly for thrombocytopenia, or a low platelet count. After ruling out the various bad actors, I got an ultrasound of his liver. Lo and behold, he had cirrhosis, probably from "fatty" liver, a growing problem in our soc...

This Is a Lot Harder Than I Thought

CancerDoc — Mon, 06 Sep 2010 22:29:00 +0100

My list of violations so far:1. forgetting my steel mug when i sometimes get coffee or tea (even though i'm trying to get rid of the habit altogether anyway)2. forgetting to bring my reusable plastic bags to the health food store and then needing another bag3. driving when i could easily walk or bike to my local coffee house/drug store/grocery4. getting tired of composting, especially since i don't grow anything5. forgetting to use my drying rack (better today, though)6. having a constant urge to buy another lawnmower (my old-school push bladecutter just does a terrible job; i feel like i'm lowering my neighbor's property values with my inability to make the lawn look even semi-presentable)this is challenging. granted, i'm a lot more aware of consumption. it's like a constant reminder to s...

Blue Gold

CancerDoc — Fri, 03 Sep 2010 17:04:00 +0100

I was watching a documentary yesterday. "Blue Gold".It was about water resources around the world and how competition for water will be a main battleground of this century.So much focus has been on global warming and declining hydrocarbon resources. Yet, one of the main consequences of both problems will be a decline in the amount of available freshwater in the world.Some contributing factors:1. contamination of available sources of groundwater and rivers by agricultural pollution.2. growing worldwide population3. a warming planet4. privatization of water in the hands of multinational companies who have no incentive to maintain clean supply or to diminish pollution.5. globalization of agriculture and other products resulting in production of non-native food that is potentially water intens...

Hospice, chemotherapy or both

Dr.Kattlove's Cancer Blog — Wed, 01 Sep 2010 22:49:00 +0100

In this study from Boston, patients with advanced incurable lung cancer, that could not be treated with surgery, were divided into two groups. One group received standard care, mainly chemotherapy and the other received the same care plus palliative care, the kind one gets in hospice. This consists of relieving pain and other symptoms, discussions of dying as a normal process, both psychological and spiritual support, encouraging of an active life and help for the family with coping with the illness.Two major outcomes were measured, which are the two outcomes we oncologists always strive for. These are improving the quality of life, the primary goal in this study, and improving its length – not a primary goal of the study, but measured anyway. Of course, the patients getting the palliati...

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Gladiators and the Forgetting

CancerDoc — Wed, 01 Sep 2010 01:35:00 +0100

Buy Nothing Year???Barely Buy Nothing Day... I managed to use my steel cup for a Starbucks coffee a couple of times, but I blocked out my conscious thought as I bought a bagel on my way to work (30 minutes after morning meditation no less).Hypocrisy starts at home, I suppose.This is going to be a whole lot harder than I thought.So, tonight. I'm feeling the jitters of someone who is a few weeks into trying to be VERY strictly vegetarian... Well, maybe one week of KINDA vegetarian.So, I'm craving something. A week of getting up at five in the morning and praying to Shiva or Narayana can do the darndest thing... like make you want to drink beer or read People magazine or masturbate...But, I let that pass. Exhale. Well, I get some beer and order a sandwich from my local eatery. Yes, in packagi...

Buy Nothing Day... or Year?

CancerDoc — Sat, 28 Aug 2010 22:13:00 +0100

I was reading some of my Walden today. Simplify, Thoreau entreats us. Live near the margin. In your mind more so than geographically, isolation/solitude/aloneness is a cleansing experience to him. Unorthodox even in his own time. Ridiculed even. But, timeless in its apprehension that what is essential in life is often not seen or understood until we strip away most of the veneer of "happiness". The clothes. The nights out carousing with people you don't even like. The pomp of titles and accomplishments. Who are you, without the externals? Without the signals that are sent to others that signify your status, your importance, your role in the hierarchy of life?What if you step outside the hierarchy? What do they see? More importantly, what do you see in yourself? The magazine Adbusters advoc...

Moksha Redux

CancerDoc — Wed, 25 Aug 2010 17:41:00 +0100

What is liberation? Moksha. This ancient Hindu concept.It is translated as liberation or release. Likened to Nirvana, the "extinguishing out" to which the Buddha awakened.I have been reading over and over these various concepts from Yoga and ancient Indian thought. They are described in various texts. You can get easy definitions from the Internet, various popular authors, a Sanskrit dictionary. But, what is it? The feeling of it?I have no idea. I'm not even close to it. There are various stories from the early sutras of the Pali Canon that characterize the Buddha after he achieves Nirvana. They are illustrative.I think of him as a humanistic, agnostic/atheist, fully-realized yogi. He achieves the mastery of his body and mind early on through yoga. Studying with two renowned teachers short...

Atha Yoganusasanam

CancerDoc — Thu, 19 Aug 2010 22:20:00 +0100

The moment is here. It's always here. It's so hard to not get caught up with the failures and regrets of the past or the fears and loathings of the future.Our minds are constantly swirling about. We are forever moving from one idea, one thought, one emotion to the next.Can we silence this?Should we silence this?The second, more famous line of the Yoga Sutras of Patanjali is "yoga citta vritti nirodah". One translation of this is that "yoga is the cessation of the fluctuations of consciousness".By slowing the mind, quieting the turbulence, we then get a glimpse of our "real self" or Self. We see who we really are, naked, alone, after removing all of the external forces that swirl around our body and mind and soul.But, the first line is key. Atha Yoganusasanam.Now, with divine blessing, the ...

A tale of two cancers. What happens after many years?

Dr.Kattlove's Cancer Blog — Wed, 18 Aug 2010 22:37:00 +0100

With most cancers, we worry about the cancer coming back after curative treatment. No cancer is a better example of this than breast cancer. Everyone always talks about 5-year survivals or cure rates. But that is an illusion. Breast cancer can come back in 10 years, 15 years or even longer. I once saw a woman whose breast cancer came back over 20 years after her surgery. No one knows why it takes so long for the cancer to recur. The good news is that in these situations it is generally slow growing - that may be one reason it took so long. But that isn’t enough of an explanation and many cite a fall off in the patient’s immune system, which occurs naturally with aging.A recent summary of all the major studies in treatment of breast cancer pointed this out rather dramatically. In a grou...

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The Fire Next Time

CancerDoc — Sun, 15 Aug 2010 15:34:00 +0100

Inner Russia.A place that more often than not is temperate to cool to plain frozen for most of the year.Well, this year, there are such devastating droughts and heat waves there that there have been significant California-esque wild fires and scorched earth. So much so that they have had to limit wheat exports, thus resulting in rising wheat and grain prices throughout the world.A third of Pakistan is now flooded, a la the usual scenario in Bangladesh. Are these just part of the normal variation in the climate or is this evidence that "climate change" is affecting us sooner rather than later?I'm unsure, although I am a firm believer that the planet is being warmed due to the actions of mankind.It is grey outside. Rainy. Dreary. But, not in a charming, English sort of way. It is gloomy, dar...

Bad news, guys. Women are catching up.

Dr.Kattlove's Cancer Blog — Wed, 04 Aug 2010 21:39:00 +0100

This is my first blog in a few weeks because I was vacationing in France. While there, I was struck by the number of women who smoked. The outdoor cafes and sidewalks were filled with them. They seemed to be puffing away like the little engine that could. So I looked into the stats on lung cancer in French women and found no surprises.First, let us look at the U.S. We guys have begun to get the message. We’ve cut down and our rate of lung cancer has dropped by around 20 percent in the last 20 years. In women, though, the rate continues to edge up so that U.S. women are getting lung cancer almost as often as men. Lung cancer is the major cause of cancer-related deaths in women in the U.S., greater than breast cancer and colon cancer combined. It is predicted that 71,000 women will die of ...

Turning the Wheel

CancerDoc — Thu, 15 Jul 2010 16:53:00 +0100

Greed. Anger. Delusion.Minimizing these three states was a primary focus of the teachings of the Buddha. In not understanding that all things are dependent or "conditionally arising" as some choose to translate, we humans grasp on to that which is impermanent. Trying to maintain a permanent hold on that which is by nature constantly changing is the source of dukha, or suffering.Our lack of understanding propels us to desire more... more sex, more money, more objects, more stuff, more experiences.Our disappointment with this never ending, escalating need for fulfillment results in anger and resentment...The source of all of this is our delusion and ignorance of the nature of reality.This helps me sometimes as I meditate on all the things that I see every day in the clinic.Sometimes, it does...

The TV news reporters were crying this morning

Dr.Kattlove's Cancer Blog — Sun, 04 Jul 2010 21:07:00 +0100

One of their favorites, the traffic reporter, Paul Johnson had died. He died of a brain tumor that had been diagnosed in January of this year. He probably had a glioblastoma, the same brain cancer that killed Ted Kennedy and my friend Richard. About 13,000 people die of brain cancer each year in the United States. Most of these people are in their later years like Johnson who was 75. Although epidemiologists have been searching hard, we haven’t a clue to why this cancer develops. We know that it occurs more often in men, in whites and, of course, in the elderly. Other than that, there is no clear-cut cause. Today’s hot item is cellphone use, but the studies so far have been contradictory. Personally, I don’t believe it. If it turns out to be a cause, it will be because young people w...

How Much Time Do I Have?

Doctor David's Blog — Sun, 27 Jun 2010 16:29:00 +0100

I think that is the hardest question I have ever been asked. The emotional weight that goes along with asking how many days are left in a child’s life is staggering. I have been asked this question many times during my career, and I still don’t know how to answer it. Some doctors answer this question based on disease-specific statistics. For example, since most patients diagnosed with a brainstem glioma die within a year of diagnosis, some will tell the family of a patient who receives this diagnosis that the child has less than a year to live. Photo Credit Some doctors answer this question based on personal experience. It is personal experience that has led me to dread this question the most. I would like to share two of these experiences to illustrate why. It was a Monday night....

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How are we doing in developing new cancer treatments?

Dr.Kattlove's Cancer Blog — Wed, 23 Jun 2010 20:20:00 +0100

Several years ago at a meeting of the American Cancer Society, where I worked, a volunteer told me how she had been saved by a new lung cancer drug called erlotinib (Tarceva). She had widespread lung cancer, which was being controlled by this drug. She was lucky. Most people don’t do as well. In general, the average increase in life span with this drug is around 4 months. And it isn’t cheap – about $20-25,000 for a course of treatment.Tarceva was designed to block a growth stimulator on the surface of the cancer cell. There are other so-called designer drugs that have been developed to block some of the mechanisms that cause cancer cells to grow. Most of these have been less successful than Tarceva and those that do succeed generally work in just a couple of cancers and don’t exten...

One stop treatment for localized breast cancer

Dr.Kattlove's Cancer Blog — Fri, 18 Jun 2010 22:00:00 +0100

In this study, once the tumor was excised, a round radioactive source (about the size of a golf ball) was placed into the excision site for about 20-35 minutes. It was then removed and the incision was closed. Not only is this quick, it is cheap.A little over 2000 women were entered into the study. Half of them received standard radiation therapy at an outpatient radiation therapy facility while the other half got the quick “golf ball” treatment right after surgery. The point of this study was to see if this new approach was as good as the standard one.And it was. After 4 years, the number of cancer recurrences in the operated breast were just about equal, whether a woman had the standard long treatment or the quick one at the time of surgery. And, the toxicity such as scarring or hard...

Yoga – Not Just for Skinny, Pretty Women Anymore?

Doctor David's Blog — Wed, 16 Jun 2010 03:10:00 +0100

This study enrolled 410 cancer survivors (96% female, 75% had breast cancer) suffering from moderate or worse sleep disturbance. The participants were randomized to standard monitoring versus a 4 week yoga intervention. Participants in the yoga program had improvements in sleep quality, fatigue, and various measures of Quality of Life compared with the control arm (no intervention). The benefit was significant enough to be covered by mainstream media outlets like CNN as well as web-based media like Breastcancer.org. ASCO president Douglas Blayney, MD, stated that the results are “readily applicable” for a huge patient population. But wait. As we scientists often ask, do the results support the conclusions? I think the answer is a resounding “Maybe.” There is mounting evidence th...

Genomic Medicine – The Hope and the Hype

Doctor David's Blog — Mon, 14 Jun 2010 02:59:00 +0100

Ten years ago this month, President Clinton, along with Drs. Craig Venter and Francis Collins, announced the completion of the Human Genome Project – the complete DNA sequence of the human genome. As is typical of such announcements, there was much pomp and circumstance, as the President declared it a “day for the ages.” Why the excitement? It was fully expected by participants in the struggle to sequence our genome that achieving this goal would rapidly lead to a new understanding of the genetics of common disease, and would yield new genomic treatments that would revolutionize the practice of medicine. In fact, Dr. Collins predicted that the genetic diagnosis of disease would be accomplished within 10 years, and treatments would begin to appear 5 years later. This, sadly, has not...

A new way to lower your risk of breast cancer (not recommended)

Dr.Kattlove's Cancer Blog — Thu, 10 Jun 2010 18:43:00 +0100

I have written a lot about the increased risk of breast cancer in fat women, particularly those who are past menopause. So it makes sense that women should start keeping slim at an early age to keep their risk of breast cancer down. Wrong!It turns out that overweight adolescent girls are less likely to get breast cancer than their skinny friends. This is something that has been suspected for a while, but no one wanted to advertise it too widely. Now, the results of a giant study, The Nurses Health Study, have verified it. Fat adolescents get less breast cancer when they grow up.In the study, researchers enrolled over 250,000 nurses (women only) in a study that began in 1975. The nurses answered a questionnaire that asked, among other things, how fat were you as a teenager. Levels of “fat...

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Which chemotherapy is right for you?

Dr.Kattlove's Cancer Blog — Tue, 25 May 2010 16:04:00 +0100

How do oncologists choose which chemotherapy is best for you? Usually they depend on past experience with certain drugs. They will look at clinical trials that show which drugs or combinations of drugs are best for your particular cancer. Most of the time, they try to balance the benefits of thee drugs such as shrinking the cancer and prolonging your life with their toxic side effects.The problem with this approach is that one size doesn’t fit all. The medical literature might say that a particular drug or combination of drugs benefits half the patients treated versus another chemotherapy regimen that works in only one-third of patients. Naturally, if the side effects are about the same, the oncologist will pick the first regimen that works in half the patients. But, how do we know those...

Another Ethical Dilemma

Doctor David's Blog — Fri, 21 May 2010 21:44:00 +0100

The ethics of modern medicine has always fascinated me, and Pediatric Oncology has provided me with more than my fair share of ethical issues to contemplate. I want to share today’s, and see what people think about this particular, emotionally charged, situation. I received an email today from a colleague in another state. He trained under me, and I guess he thinks I did a good job, since he emails me for advice from time to time. He met a new patient today – a 23 year old woman with a new diagnosis of osteosarcoma. Unfortunately, she is 20 weeks pregnant. One of the mainstays of osteosarcoma treatment is high dose methotrexate. Methotrexate is a very effective drug for terminating pregnancies, and this is where the ethical dilemma begins. The patient has a choice to continue her pr...

How Small a Chance Is Too Small?

Doctor David's Blog — Tue, 18 May 2010 02:51:00 +0100

I’ve written about difficult cases before, but this case is really eating at me. It touches on issues of patient autonomy and how much influence we, as physicians, have over our patients. But the real issue is one of futility. How small a chance at survival is too small to offer a very toxic treatment? The patient is a young boy with leukemia. We have been treating him for over a year, and his leukemia just won’t go into remission. For the past 3 months he has been in the hospital, first to receive chemotherapy and then to manage the side effects we caused. His bone marrow is nearly empty, but almost 80% of what few cells are present are leukemia cells. His only potential curative therapy is a bone marrow transplant. Therein lies the problem. Not only does he have refractory leukemia...

It’s not the chemicals, it’s us!

Dr.Kattlove's Cancer Blog — Tue, 11 May 2010 16:43:00 +0100

This week, the President’s Cancer Panel came out with a new report on chemicals in the environment. They worried that these 80,000 chemicals with unknown health effects could be causing cancers in some of us.Forget about it! As my former colleague, Michael Thun, chief epidemiologist at the American Cancer Society, said, there are a lot more cancer-causing risks to worry about than these chemicals. Let’s look at smoking, the most important cause of cancer other than living a long time. Many of us teach that we really begin to worry about the risk of lung cancer in a smoker who has a “twenty pack-year” history. That is, he has smoked a pack of cigarettes (20) a day for 20 years (or 10 cigarettes a day for 40 years). That represents a huge intake of cancer-causing chemicals from cigar...

Fifty thousand is too many!

Dr.Kattlove's Cancer Blog — Thu, 29 Apr 2010 23:40:00 +0100

That is how many people die of colorectal cancer each year in the U.S. This number can be reduced. Lives can be saved.Today’s newspaper carried a study from England on the benefits of sigmoidoscopy in lowering the death rate from colorectal cancer. The study was published online by the British journal, Lancet. Over 170,000 people participated in the study. Their ages ranged from 55 to 64. Of these, 57,000 were assigned to have a sigmoidoscopy while the others served as a control group. Naturally more cancers were diagnosed in the people who had the procedure (almost three times as many), but more important was that fewer of them died from their cancer. Depending on how you read the statistics, the chances of dying from the cancer was cut by 30 to 40 percent.Sigmoidoscopy is a simple proc...

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M

CancerDoc — Wed, 28 Apr 2010 02:56:00 +0100

is my friend. Lover. Ex-lover. Inspiration. Source of a lot of joy, some occasional pain, and a whole lot of thinking. M has helped me understand myself. Helped me to accept myself. Not be afraid of life. Not be afraid to be alone. M is the only other person I've ever met who matched all my crazy interests and enthusiasms for things.She has similar belief structure. She is crazy. In a good way. But, crazy nonetheless.She excites me. Frustrates me. Titillates me. Challenges me. Saddens me. Breaks me. And makes me whole again. Every cliche you can think of... well, you get the point.It is funny in life how you can know some people for a long, long time and never feel close, like that sibling that you never really connect with.And then there are these people that cross through your life for ...

Om

CancerDoc — Fri, 23 Apr 2010 02:17:00 +0100

How on earth did anyone figure out that the three-syllabic A-U-M sound has cosmic overtones? Or at least that it was pretty cool. I wonder this sometimes, like tonight, when I lay down after yoga. Yoga, derived from the Sanskrit root, yuj...To yoke, as in yoke a team of animals. Or join. As in your body to your inner consciousness. The Buddha used yoga to strengthen his body and mind to gain insight into the deep realities of life.In America, we use it to get "buns of steel" and look good in spandex. I'm not sure where it's standing for me so far. Probably more the "deep reality" type stuff, but let's not discount the superficial just yet. A lot of emotions turn over in your mind as you sit there about to collapse in your headstand.Your day flashes by. Love. Anxiety. Your fears. Then, noth...

Can lethal prostate cancer be prevented? Not yet!

Dr.Kattlove's Cancer Blog — Thu, 08 Apr 2010 17:20:00 +0100

Well, there is one way. Die young. Prostate cancer is a disease that mainly affects older men. In fact, autopsy studies have found that nearly half of men in their 70’s and 80’s will have cancer in their prostate. Scary, huh? Well the truth is that most prostate cancers are not killers. Every year about 200,000 cases are diagnosed. Yet only about 25-30,000 men die of this disease. But the drug companies keep trying to promote a treatment for a problem they can’t solve. This is what the headline in my local paper said the other week: “Prostate cancer drug may work as a preventative”. Check out the word “may”. Here is the issue. There are drugs on the market that are intended for men with enlarged prostate glands. The drugs can shrink the prostate gland by blocking the action o...

Do oncologist think, ”How much money will I make on your treatment?” You bet they do!

Dr.Kattlove's Cancer Blog — Fri, 26 Mar 2010 22:20:00 +0100

One of the most disturbing things I learned in my days at the UCLA School of Public Health came in my economics course. The professor had us read studies that showed that doctors would practice in ways that provided the most income. Although this is human nature, it isn’t what we expect of doctors. We expect altruism - only the welfare of the patient counts. Well it just isn’t true.A recent study has found that oncologists will use the most expensive drugs that give them the highest profits. In the past, one obstacle to giving drugs, mainly chemotherapy (and patients accepting them) was their side effects. Patients would often suffer too many side effects to make it worthwhile. But now, most of the newer and more expensive drugs have fewer side effects (and often less benefit) so that ...

Denmark

CancerDoc — Sat, 20 Mar 2010 22:02:00 +0100

R.N. just died. She was my first breast cancer patient out of fellowship and training. My first breast cancer patient where I was the "doctor". No backup. Nobody to turn to for advice. I write the orders, I explain the side effects. I hold the hands.She was only 33 years old when she was diagnosed 4 years ago. She and her husband had just moved from Denmark only months before for his company. Something with maritime equipment that brought him to the mid-Atlantic. Then she found the lump. A small, 1 cm mass in her breast. So young.Triple-negative. A bad prognosis.But, still stage I. She got chemo, lots of chemo. bilateral mastectomies. We took her ovaries out when we saw that she had a genetic predisposition to breast and ovarian cancer.All the while, I learned a little bit about Scandinavi...

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Symptoms of ovarian cancer - do they help catch it early?

Dr.Kattlove's Cancer Blog — Fri, 12 Mar 2010 23:38:00 +0100

Ovarian cancer can be looked at as kind of a silent killer. Most of my patients usually had only vague symptoms before the cancer became widespread and was too far gone for a cure. But lately there has been a look at whether doctors or patients are ignoring these early vague symptoms of ovarian cancer. This is important because it is such a deadly disease and any chance of catching it early may help some women. Right now, a little over half of women diagnosed with this cancer die within 5 years and this death rate has fallen only slightly in the last 20 years. There haven’t been any “breakthroughs” in treatment.Because new treatments haven’t been discovered that would improve the cure rate of women with ovarian cancer, a lot of attention has been directed toward detecting it early....

The Irony of Patient Autonomy

Doctor David's Blog — Mon, 08 Mar 2010 03:04:00 +0100

One of the cornerstones of medical ethics is the concept of patient autonomy. MedicineNet.com provides a succinct definition: “The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.” At lunch the other day, I was talking about a particularly challenging case when this concept came up. After thinking for a few minutes, I was struck by a sense of irony that I wanted to share in case others have thoughts about this. The patient is a teenager with leukemia. When she was diagnosed with leukemia, we didn’t really give her parents any choices about treat...

I was wrong – transplants work for multiple myeloma

Dr.Kattlove's Cancer Blog — Thu, 04 Mar 2010 00:28:00 +0100

Multiple myeloma is a disabling disease of the bone marrow. It stems from a cell called the plasma cell, occurs in older folk, and because it is mainly confined to bone often causes them to hurt, if not break. I remember a patient with the disease whose bones were so fragile, she broke her arm while combing her hair.Over the last 10 years, treatment has improved. During most of my practice years, the main treatment was a pill called melphalan. It didn’t cause many side effects and often the disease would remit for a while – maybe even a few years. But it always came back and there wasn’t much we could do at that point. Then someone came up with the idea of giving these patients high doses of melphalan intravenously. This would normally kill them because although most of the myeloma c...

Brain radiation may be hazardous to your mind.

Dr.Kattlove's Cancer Blog — Thu, 18 Feb 2010 16:57:00 +0100

Early in my practice, one of my patients, a 60 year old with lung cancer complained of headache. Her lung cancer had been cured by chemotherapy – she had what we call a small cell cancer, which is very sensitive to chemotherapy and can, at times, be cured.But this less common form of lung cancer tends to spread quickly and widely. The chemotherapy probably killed most of the cancer cells that had fanned out through her body. But chemotherapy doesn’t usually penetrate into the brain and that was where the cancer had spread. A CT scan of her brain showed a tumor. The usual treatment at that time was radiation treatment to the whole brain. The reasoning was that if there was one tumor, there were probably more that we couldn’t see so it was better to get rid of them all. So that is what...

The Snow That Heals

CancerDoc — Mon, 08 Feb 2010 23:53:00 +0100

A curious thing happened to me today. I had several really wonderful interactions, all due to shoveling snow! How strange.I live in a nice, family oriented community in Baltimore, rowhomes mainly, populated by 30ish and 40ish couples with young children. Having no children myself, I often smile a lot to everyone playing outside, but rarely interact. Other than to grunt as I come home late and can't find a parking spot or laugh when a neighbor's dog jumps the fence into my yard or look curiously when children play endlessly on a patch of grass and stones in my front yard. But, yesterday and today... during "Snowmageddon" here in the Mid-Atlantic, I've been shoveling like a you-know-what. And, so have all my neighbors. And their kids. And their dogs. And mothers. And husbands and wives. And,...

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If I developed acute leukemia.

Dr.Kattlove's Cancer Blog — Sun, 07 Feb 2010 19:48:00 +0100

I’ve often wondered what I would do if I developed acute leukemia. When I was in my 40’s or 50’s there was no question that I would go for the most aggressive treatment. Even in my 60’s, especially early that would also have been my choice. But now, a little past 70, I’m not so certain about what I would do.At one time, early in my practice, I treated several patients over 60 with acute leukemia. Almost all of them did well – for a while. I treated them with the standard chemotherapy (which, unfortunately, hasn’t changed much in the last 30 years). They developed the usual side effects, which made them pretty sick, but recovered and went on to pretty good lives for a while. But, after a year, more or less, their leukemia came back and couldn’t be treated and they all died.N...

Avoidance

CancerDoc — Wed, 03 Feb 2010 19:52:00 +0100

I feel so withdrawn.Empty.Attached. The Buddha teaches that life is suffering. Dukkha. The root of that suffering is in our desire, our attachment to our wants. The more we desire, the more suffering we feel when that thing, that person, that feeling is lost. As it inevitably will be lost.We all decay and die.Life is an illusion.I hurt someone very dear to me today. Someone I care for deeply. Who I love.I feel it as a result. I know it will pass. As all things do.But I feel it nonetheless. (Source: CancerDoc)

Why David Hates Health Insurance Companies

Doctor David's Blog — Tue, 02 Feb 2010 15:53:00 +0100

A Rant Photo Credit I am involved in a case right now that epitomizes all that is wrong with commercial health insurance. All in one case. How convenient. My patient is a young adult with a sarcoma diagnosed in her liver. There is one large mass and several smaller ones. The tumor is not resectable right now, so she will need chemotherapy. Two issues have arisen this week: one related to diagnostic imaging (radiology) and the other related to quality of life. With both issues I have faced significant roadblocks, placed by the patient's insurance company, that impede my ability to provide the care this young woman needs. I'll start with the imaging issue. The patient's sarcoma is not one that typically arises in the liver. Also, the prese...

Death and the Maiden

CancerDoc — Mon, 01 Feb 2010 18:41:00 +0100

My partner's sister just died. 28 years old, pregnant with twins. A complication in the third trimester. The liver enzymes go up, the blood counts go down. Babies come out of Mom.Dead.Mom goes into organ failure. Dialysis. Ventilator. Bleeding. Dead as well.I don't know this women. Or rather, I didn't know her. We forget sometimes how dangerous pregnancy can be. In times past, many children never survived to adulthood. Maternal complications were so frequent and severe.But, we live in such a different world now. We all expect pregnancy and childbirth and the first years of life to be so wonderful. We are just stunned when it goes wrong.I'm stunned.I can't imagine what her husband is feeling. Life, about to be realized fully with the birth of the first children... now, destroyed. No childre...

Health Care Debacle

CancerDoc — Tue, 26 Jan 2010 18:41:00 +0100

I have to say, if this is "Change You Can Believe In", I might need to drag GWB back into office. I'm about as progressive as they come, but there is something real to this whole Scott Brown/Massachusetts backlash/potential collapse of the health care bill.Leave it to Congress to produce something no one has read, understands or cares about. To produce something that does little to control entitlement cost and growth. Something that does little to help tort reform. Almost nothing to deal with the perverse incentives for physicians and hospitals that underlies the cost and poor quality of our system. Rather, it's a bit of a grab bag of giveaways to various lobbying groups, from Pharma, to Hospitals, to Docs to Insurance. It lacks VISION. Obama has not done a good job communicating a VISION ...

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How much should cancer treatment cost? How much is too much?

Dr.Kattlove's Cancer Blog — Thu, 21 Jan 2010 22:13:00 +0100

This is a question that has been bothering oncologists for several years, but has gotten even more troublesome lately. New drugs are being developed that cost tens of thousands of dollars a year yet aren’t saving or prolonging many lives. I’ve written about this before, but now we are seeing surveys of what other oncologists think.The latest survey just appeared in “Health Affairs” (January 2010), a journal devoted to articles on the delivery of health care and its cost. The authors surveyed nearly 1400 oncologists from throughout the U.S. and asked them how the high costs of the newer drugs affected their decisions. Their answers made sense, but are troubling.When asked if cost affected which drugs they would use, 56 percent said it did. Even more startling was that the patient’...

Nurse C.

CancerDoc — Mon, 18 Jan 2010 14:38:00 +0100

Caring for cancer patients is hard enough. Caring for someone that you work with is that much harder. I suppose caring for a loved one that you work with would be the ultimate in emotional pain, but thankfully, I have yet to experience that one.K.C. is... or, as of this morning, was a 50 year old patient of mine with metastatic ovarian cancer. She worked as a floor nurse in Oncology at the hospital where I attend. A wonderful woman. Just a positive ray of sunshine for anyone who knew her. A family woman. Kind and loving husband. Wonderful teenage children. Loving. Just the kind of person who dies.Diagnosed in 2007 with stage III ovarian cancer (the most common presentation), she had the usual surgery and chemotherapy. Like so many woman with her condition, she recurred within a year or so....

Why don’t you tell your oncologist what you want?

Dr.Kattlove's Cancer Blog — Thu, 14 Jan 2010 19:09:00 +0100

Why don’t cancer patients talk to their oncologist about what to do when treatment fails and the cancer is progressing? Do they want aggressive therapy; do they want cardiac resuscitation, IVs, everything done, only comfort measures? They are actually more likely to talk about it to some strange doctor who just admitted them to the hospital or to their primary care doctor. This is something that was discovered about ten years ago and now a new study found that it is still true. Cancer patients are reluctant to talk to their cancer docs about their care even if the situation looks grim. The new study, published in the January 10, 2010 Journal of Clinical Oncology, interviewed 75 seriously ill cancer patients who had been admitted to the hospital.Most of them said they would not want to in...

The Fear That Kills

CancerDoc — Wed, 13 Jan 2010 17:34:00 +0100

I just saw a 50 year old woman with a large 7 cm right breast mass and a scan that shows her liver and bones to be riddled with tumor. Breast cancer. Metastatic.She's very intelligent. Pretty. Educated.Oh, did I mention that she's a nurse?WTF?Divorced, living alone, she knew that this was cancer. She knew she should have it examined and biopsied. But, she was afraid.She noticed it a year ago... that's right. ONE YEAR AGO.It was small then. It was probably curable and early stage. Just like so many other women. Just one of the "1 in 9" that get it.I can't tell you how many times I've seen this in patients. Not just the subtle weight loss or a nagging ache in the spot of an old injury.No. I'm talking about large mass coming out of the breast or skin or neck or leg.I'm talking about bleeding,...

Love

CancerDoc — Tue, 12 Jan 2010 02:21:00 +0100

is an ephemeral thing. It swoops in, takes charge of your existence, turns on a form of madness in your brain and then often leaves you exhausted. Love is passion, heat and whispers, mumbling and smooth textures. It burns.Love is hot. That is, before it goes cold and unfeeling.Love is nurturing. Maturing. Snuggling. Cuddling. Love is nursing. Touching the neck. Sweeping the hair back.Love is loyal. Sometimes. Sometimes it is deceitful.Love is gain.Love is loss.Love is what we all aspire to have.Love is what makes us all miserable.Love is dedication. It is pure. It is good.Love is betrayal. It is base. It is evil.I have been fortunate in life to have loved deeply, to have lost love, to have spurned and been spurned by love. I have run away from it as much as towards it. I fear it. Is love ...

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Lets talk about bald kids.

Dr.Kattlove's Cancer Blog — Thu, 31 Dec 2009 16:56:00 +0100

I’m talking about children who have been treated for cancer. Invariably, the chemotherapy makes them bald. They make great poster children to advertise children’s cancer centers, but they often don’t end up smiling as they do in the posters. Although their hair grows back, other organs are not so lucky. Virtually all organs can be damaged by their treatment. Their heart, their thyroid gland as well as other glands can suffer. And they have a high risk of developing a new cancer. Girls have an especially high rate of developing breast cancer as they mature. Also, many children will have problems with development and learning.Now cancer in children is not that common. Only about 16,000 cases are diagnosed each year. The good news is that around 80 percent are cured so there are a lot o...

The Ties That Bind

CancerDoc — Wed, 23 Dec 2009 17:23:00 +0100

Home. As I stare out of my window at the office, looking at the people try to navigate the snows here in Maryland, milling about, hats on heads, gloves, wool coats flapping in the wind, I think about the concept of "home". I grew up in Los Angeles. Well, part of the time there. Bronx, to Westchester County, to Oklahoma, then California. But, West L.A. was my home from middle school to high school and was formative. Sunny, wealthy, diverse. There were 10-20% Iranians in my high school. It was predominantly Jewish otherwise. 99% of the people went on to college. Every Ivy League school was represented on my block, both in the parents and in their children.It was privileged to say the least. But, strangely, it never felt like home to me. There was an artificial quality to it. Maybe it was bec...

What Does A Cure Mean?

CancerDoc — Wed, 23 Dec 2009 15:41:00 +0100

"I'm cured, right?" "Yes.""So, why can't I walk?""Well, it's not as simple as that.""The cancer was in my back, right? You said it was in my back? Now, it's not. Now, it's CURED..."It's been 2 months since K.S. finished her chemotherapy for lymphoma. She had had some low back pain for a couple months. She saw her primary doc who had ordered an initial set of spine films and started some physical therapy.I mean, she's only 40-something, busy in life with kids, family, etc. Moving boxes, bending to get a casserole, having sex... there are a million reasons why a woman her age can get a little back ache.Who would have thought it was an aggressive lymphoma eating into her vertebra and eventually compressing her spinal cord?Well, that is until she one day just started urinating on herself, slip...

Fishing, and the Kindness of Strangers

Doctor David's Blog — Wed, 23 Dec 2009 05:16:00 +0100

The ability of the internet to catalyze spontaneous events is not limited to Rickrolling or snowball fights. I want to tell a story of the power of the internet, and how it can harness all that is good in people, allowing total strangers to reach out to someone in need and do something special. One of my patients is a 19 year old young man whose cancer has proved resistant to most every treatment he has tried. Last year, when he was in remission and feeling well, Make-a-Wish granted his wish to go deep sea fishing with his family. T had a great time, and his only regret was that he did not hook a fish large enough to need to be “strapped in.” Last month T and his mother met with our team (me, the fellow, the nurse, and the social worker) to discuss participating in a clinical trial....

Is cancer care advancing?

Dr.Kattlove's Cancer Blog — Tue, 22 Dec 2009 17:09:00 +0100

Every year the American Society of Clinical Oncology publishes what it considers to be the major advances in cancer care for the year. This year’s news was not very encouraging.Let’s look at prostate cancer, particularly those of us guys who get screened regularly. The big advance, according to ASCO was that two large clinical trials found that routine screening for prostate cancer with the PSA blood test “has a small effect, if any, on reducing prostate cancer mortality”. What a bummer for all of us who get our blood tested religiously.Maybe this is why they add, that “US cancer screening rates are low or declining”. Or could it be that lots of Americans have no health insurance?In spite of all this screening, some men develop prostate cancer that invades outside the prostate ...

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I'm Focused On Living

CancerDoc — Mon, 21 Dec 2009 16:41:00 +0100

"I'm focused on living right now, ON THIS...", she said, pointing to her maimed left breast, as I asked her about loneliness and dating. Then she smiled... "but next year, when my reconstruction is done, watch out." I'm focused on you, S.G. It's hard to see someone sick at any age. I don't deal with pediatrics so that is often abstract to me. Honestly, for the patients that are 70 years old and older, part of me thinks that their suffering is a tragedy, but that this is part of the cycle of aging and life. Maybe I'll feel differently when I'm that age.But, for the 30 and 40 year olds like S.G., struck down with the lymphomas and leukemias and breast cancers and testicular cancers... it's different. They are "young", my age and can articulate their loss and their potential loss so well. The...

Ode To The Gas Passer

CancerDoc — Thu, 17 Dec 2009 23:45:00 +0100

I just heard that a colleague of mine killed himself two days ago. An anesthesiologist. Trained at the same hospital that I came from. Wife. Family. The whole shebang. I don't know the whole story, but apparently, he had been depressed for some time. He had tried once before.All of this was triggered a year ago by a complication involving a pregnant young woman. First child. 27 years old. Supposed to go well. It didn't.She died.He was involved. He thought he did it. An epidural gone wrong or some crap like that. Just some horrible unforeseen shit went down and he happened to be involved. So, it ate at him. Maybe there was some prior depression. But, this doesn't help. So, he finally killed himself.I never even suspected a thing. I would talk with him about common patients in the hallway, a...

A Long Year for Mike

Doctor David's Blog — Thu, 17 Dec 2009 05:36:00 +0100

A year ago this week, Mike's sinuses were acting up again. It wasn't uncommon for Mike to have sinus problems during winter, but last December things were worse than usual. A trip to his pediatrician led to a CT scan. The scan found a mass, not a sinus infection, and that's how Mike and I met. Mike spent last Christmas worrying about the mass in his sinuses, and whether it was cancer. After a year of surgery, chemotherapy, and radiation, Mike celebrated a very important day earlier this month: End of Chemo Day. We celebrated with Mike in clinic. His family brought trays of sandwiches and desserts to share with the staff. Mike plays guitar, so he had a special cake. The food was awesome, the cake was divine. But the best part of the day? ...

Christmas

CancerDoc — Tue, 15 Dec 2009 03:02:00 +0100

Another holiday approaches. I am not Christian, as anyone who reads my blog would surmise. But, the message of Jesus is one that resonates strongly with me. I suppose it is universal in its appeal. I try to think of Jesus as a historical figure. An itinerant preacher amongst the Jewish poor, preaching a message of faith, charity and love. This, despite Roman oppression. Despite poverty and sickness and despair. Despite venality and sensuality. How this message of hope for a better, more just afterlife must have provided such comfort for those who were the most downtrodden in life. I would hope that we all would reflect some time, amidst the crass materialism of the "holidays" and think of how we can, in our own way, in this singular life of ours, strive for more justice and generosity in o...

Camus

CancerDoc — Mon, 14 Dec 2009 04:03:00 +0100

I've been listening to my books on tape quite a bit recently. Actually, more of a lectures on tape. Albert Camus. That is the latest fascination. I've finished the piece on "The Stranger" and they've moved to the "Myth of Sisyphus". It's not light reading, to say the least. A bedrock of Existential thought, Camus provided some core principles that later philosophers such as Sartre expanded and modified. The nutshell of his thinking is that life is fundamentally absurd. Devoid of intrinsic meaning. That there is no God. And that are deluding ourselves by thinking that there is a rhyme or reason to the nature of the universe. There is only life and then death. Nothing more. And that simple fact makes each of our finite lives difficult and ultimately doomed. One solution is suicide. Terminate...

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The Holidays

CancerDoc — Sun, 13 Dec 2009 00:05:00 +0100

I find the holidays somewhat depressing. Maybe it's the juxtaposition of cancer opposite the Hallmark messages that surround me. Maybe I'm just a curmudgeon. I saw four people yesterday with new cancer diagnoses. All under the age of 50. Young. I'd like to think that I've become more toughened to the nature of suffering, but I'm not sure that is the case. If anything, I feel more sensitive as I get older. I'm not sure why. Maybe it's my own mortality. Maybe I've just come to recognize that there is no judgment of the value of a life. That it is essentially absurd and intrinsically meaningless. But, to each of us, there is some existential meaning that we construct for ourselves. And, after being a doctor now for more than a decade, I accept that our lives are precious, if only for the fact...

Not Medically Necessary

Doctor David's Blog — Fri, 11 Dec 2009 03:53:00 +0100

After a courageous 5-year battle, R lost his fight with cancer. He lived a good life while he was being treated, finishing high school, starting college, and checking items off his bucket list. This holiday season is hard for his family. His absence is palpable … and painful. What could make this time any worse? The letter they got from their insurance company. Apparently I ordered a CT scan back in September. The insurance company sent the family a letter telling them that they have deemed the scan “not medically necessary,” and they are refusing to cover it. I’m used to the things health insurance companies do to try to avoid “medical losses” (their term for payments made to health care providers). I often have to fight with them when they don’t want to cover treatment ...

Maybe vitamins cause cancer!

Dr.Kattlove's Cancer Blog — Tue, 08 Dec 2009 22:45:00 +0100

I take vitamins. I’ve read that about half of Americans also take them. Why not? Can’t hurt and may help, right? Maybe not. A few years ago, doctors thought that smokers taking beta carotene, a vitamin A-like chemical might be protected from developing lung cancer. So a big study was started that tested whether heavy smokers might lower their rate of lung cancer if they took beta carotene. Not only did the vitamin not lower their rate of lung cancer, it seemed to increase it by nearly 20 percent. Other vitamins have also failed to prevent cancer. Vitamin E was tested as a defense against prostate cancer and failed. When I was in practice, we tested vitamin C in patients with cancer. This vitamin had been proposed as a life-saver by the Nobel Prize-winning biochemist Linus Pauling. But ...

More What You'd Call "Guidelines" than Actual Rules

Doctor David's Blog — Sun, 06 Dec 2009 05:00:00 +0100

Of course, Captain Barbossa was referring to The Pirate Code, but he could just as easily have been referring to documents released last month by the US Preventive Services Task Force or the American Congress of Obstetricians and Gynecologists (ACOG). In an unanticipated coincidence, these two groups, operating independently, reached similar conclusions about commonly utilized screening tests: mammograms and Pap smears. Both groups reviewed the data and concluded that routine use of these screening tests, as currently recommended, may not be warranted. Much newsprint has been expended since then discussing the political implications of these new recommendations. As this is not a political blog, I will leave that discussion to others. What I want to talk about is how guidelines ...

A Smarter War on Cancer

Doctor David's Blog — Mon, 30 Nov 2009 02:36:00 +0100

The headline in the Washington Post caught my eye: “Fighting a smarter war on cancer,” [sorry, you must register to read the article] an opinion piece by Dr. John Marshall, a faculty member at the Lombardi Cancer Center in Georgetown. It is about the intersection between health care reform and cancer care - it seemed like just the thing to read while drinking my morning coffee. But halfway through the article I found myself feeling marginalized, and that got me thinking. Although Dr. Marshall makes some good points, I think he missed a golden opportunity to propose changes that could make a real difference in our lifetimes. How did Dr. Marshall make me feel marginalized? He wrote the following about chemotherapy: “The most common approach to treatment involves exposing larg...

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If the chemotherapy is working, don’t stop.

Dr.Kattlove's Cancer Blog — Fri, 27 Nov 2009 21:57:00 +0100

I once had an elderly patient with colon cancer that had spread to her liver; she had lived for five years on chemotherapy. In fact, about one year after starting treatment, the CT scans of her liver could no longer spot her cancer. She felt well on the treatment so we kept it up, since in those days, all we had was 5-FU, a relatively non-toxic drug as these things go.But, after 5 years, she tired of the whole process, particularly since she lived about 20 miles away and the injections were given weekly. After a long discussion about the pros and cons of stopping treatment, we agreed to hold the chemotherapy and see what happened. Unfortunately, what happened was that her cancer returned in about 6 months and didn’t respond to the 5-FU this time around. A year later, she died.This week�...

The new mammography guidelines got it right!

Dr.Kattlove's Cancer Blog — Thu, 19 Nov 2009 01:07:00 +0100

This week a panel of outside experts, commissioned by the United States Preventive Services Task Force, concluded that mammography should not be routinely recommended for women under age 50 and those over age 50 probably only need mammography every 2 years – until they reach 74. I know this is controversial and emotional, but the facts are that most women under age 50 will not benefit from screening mammography and women over 50 need it only every 2 years. Why can I say this? Doesn’t mammography catch breast cancer early and save lives, regardless of age? The simple answer is “not really”.Many years ago, shortly after receiving my masters degree in public health I searched around for something to do with it. I approached Dr. Robert Brook who headed the RAND health policy unit and h...

When Bad Things Happen to Famous People

Doctor David's Blog — Mon, 16 Nov 2009 04:13:00 +0100

In a press release issued earlier this week, former NBA star and actor Kareem Abdul-Jabbar announced that he has been diagnosed with leukemia. Specifically, he has chronic myeloid leukemia (CML). Abdul-Jabbar went on to say that his disease can be managed by taking daily oral medication and he expects to live a long healthy life. With leukemia? How is that possible? Abdul-Jabbar has benefited from one of the first and most exciting applications of the translational research I have blogged about in the past. Before 2000, CML was treated with a combination of a chemotherapy drug called cytarabine and another drug called alpha-interferon. Patients treated with this combination usually responded well, but none were cured. The only curative treatment was a bone marrow transplant, and in adu...

Kareem has leukemia!

Dr.Kattlove's Cancer Blog — Thu, 12 Nov 2009 00:24:00 +0100

Almost exactly 10 years ago, I was attending my first meeting of the American Society of Hematology as an employee of the American Cancer Society. But, instead of attending meetings, I spent much of my time on the phone with reporters. It was at that meeting that the results were reported of the first clinical trials in patients with chronic myelogenous leukemia (CML) of imatinib, the drug later named Gleevec. Because the results were so outstanding they became national news and as the “expert” at the ACS, I was asked to talk to reporters who dialed the ACS number for information.Great “breakthrough” drugs for treating cancer rarely live up to their press hype. This one did. Before Gleevec became standard therapy for CML, the diagnosis was a death sentence. The term chronic meant t...

Another look at EPO

Dr.Kattlove's Cancer Blog — Thu, 05 Nov 2009 17:00:00 +0100

Another review, this time of nearly 14,000 cancer patients has found that treatment with erythropoietin (EPO, Epogen, Procrit, Arensp) may be harmful to your health.Erythropoietin is a naturally occurring hormone that we all have. Its role is to help us make red blood cells. Without it, we would all suffer from low blood counts – anemia. Many years ago, drug companies learned how to make this hormone and it proved to be very successful in treating patients with anemia due to chronic diseases – particularly people with far advanced kidney disease. It raised their blood count and they felt better.Cancer patients can get anemic also – either from the cancer or the treatment – radiation, chemotherapy. So the marketing people at Amgen, the major suppliers of this drug reasoned it would ...

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As Breast Cancer Awareness Month Draws to a Close

Doctor David's Blog — Thu, 29 Oct 2009 02:01:00 +0100

As breast cancer awareness month draws to a close, I wanted to highlight a few breast cancer posts from other medical bloggers:Suture For a Living asks: "Is Breast Cancer Over-Diagnosed?"Bayblab writes about research on a diabetes medication killing breast cancer stem cells.Science Update Blog discusses claims that we are "Two years from breast cancer cure".Highlight Health's Allison Bland says "The Review is in: Lifestyle Changes Prevent Breast Cancerand Healthcare Hacks discuss the benefits of weightlifting in breast cancer survivors. If you've found any interesting breast cancer blogs or posts, link to them in the comments!Related posts:Does Vitamin D Help Prevent Breast Cancer?Breast Cancer Risk & AlcoholCancer Stem Cells and Familial Cancer Risk for Breast Cancer (Source: Doctor ...

Goodbye, Mr. B

CancerDoc — Tue, 27 Oct 2009 00:33:00 +0100

Today was a somewhat bad day. I mean, I've had quite a few bad days in my years on this planet. But, this one was up there in terms of pure badness. It started as the usual. Not too busy. Rounds. Paperwork. Returning some calls. Waving to some of my chemo patients.Mr. B. A wonderful man. A wonderful family. A "country boy", as his daughter calls him. Tough. Salt of the earth. Decent. You name the cliche, he fits the bill. Truly a good guy.But a smoker. Big time smoker. Did I mention how much I f.ing hate smoking? I met him a couple months ago... well, "met" isn't quite the description, since he was intubated and sedated. He had just been diagnosed with a new lung cancer. A huge tumor sitting right near his pulmonary artery, filling his right mainstem bronchus. He couldn't breathe. So, in w...

Breast cancer surgery: Surgeons are getting it right.

Dr.Kattlove's Cancer Blog — Tue, 20 Oct 2009 21:53:00 +0100

This week’s Journal of the American Medical Association (October 14, 2009) published an article that surveyed what kind of surgery was being done for breast cancer. They looked at patients in Los Angeles and Detroit and found that three-fourths were getting lumpectomies (called breast conserving surgery) while the rest were having their entire breast removed (mastectomy).This is a remarkable turnaround from when I was in practice. I remember one surgeon telling me that he would never do a lumpectomy for breast cancer. Many other surgeons also felt that way. Unfortunately they were relying on an old tradition that really did not apply to patients we were seeing those days.The radical mastectomy was developed around 1900 by a Johns Hopkins surgeon named William Halstead. In those days, wom...

The Sarcoma Program Goes 21st Century

Doctor David's Blog — Thu, 15 Oct 2009 01:15:00 +0100

Modern technology impacts everything we do. The very fact that you are reading these words attests to how technology touches your life.Well, the Johns Hopkins Sarcoma Center has engaged Web 2.0, too. If you follow this link, you will hear a podcast featuring my partner, Dr. Kristy Weber, the chief of orthopedic oncology at Johns Hopkins.Bruce Shriver, one of the founders of the Liddy Shriver Sarcoma Initiative, asked me about chemotherapy for high grade sarcomas, and you can see that video here. An article in their online newsletter, ESUN, discussing my laboratory's research, is here.Over time our group will be producing more podcasts. I will post links to them as they appear.Related Posts:Sarcoma VideoHear Me on the Doctor Anonymous Show!I'm on Facebook! (Source: Doctor David's Blog)

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Doctor David's Blog — Tue, 13 Oct 2009 13:15:00 +0100

(Source: Doctor David's Blog)

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Tamoxifen for breast cancer: How’s your CYP2D6?

Dr.Kattlove's Cancer Blog — Mon, 12 Oct 2009 23:56:00 +0100

I often told patients who asked, that I didn’t know how they would react to a drug. Would they get better, would they have side effects? I could tell them about average patients, but I would also say that every patient is a new experiment because in some way, big or small, everyone reacts differently to a drug.Well now, we can predict a little more about how breast cancer patients will respond to tamoxifen. It turns out that tamoxifen isn’t all that active as a substance that kills breast cancer. Before it can do its job, the tamoxifen needs to be changed in the body into much more active substances called endoxifen and 4-hydroxytamoxifen. It is these chemicals that actually knock off the cancer cells.We now know how tamoxifen gets changed into the killer chemical. A certain enzyme (en...

I went in to say "Good bye"

Doctor David's Blog — Sun, 11 Oct 2009 23:01:00 +0100

We knew this day was coming. Over the summer her cancer came back even though she was getting chemotherapy. We switched gears, giving radiation and chemotherapy aimed at controlling pain, no longer at curing disease. But that doesn’t make this day any easier.Overnight, last night, it became harder to breathe and her pain worsened. A chest x-ray showed almost no air getting to her left lung. Hoping there was fluid that could be removed, she had a CT scan today; but there was no fluid, only tumor. Tumor that hadn’t been there 10 days ago.I went in to the hospital today, to see her one last time before she went home. We watched some of the football game together. We talked about her kindergarten teacher, a brave woman who was a tremendous support before she died of breast cancer in August...

It's Wednesday... The Doctor is Playing Golf

Doctor David's Blog — Thu, 08 Oct 2009 01:09:00 +0100

What a horrid, 50's-era cliche!But today, it was true. This afternoon I played golf in a fundraising tournament for the Heather Brooke Foundation. This is a foundation named in honor of a patient with Ewing's Sarcoma that I once helped care for. When Heather passed away, her mother channeled her grief into helping others. The Heather Brooke Foundation exists to help conquer childhood cancer and to help and educate the families of children with debilitating illnesses.Today was a beautiful day for golf... if you like playing in gale force winds! Of course, if you're as terrible as I am (other than Putt Putt, today is the 3rd time I've played golf in my entire life), the wind really doesn't matter so much.But for my buddy Dean, who really plays quite well, the wind was a problem.We played at ...

More About Patients and the Press

Doctor David's Blog — Mon, 05 Oct 2009 03:07:00 +0100

I have blogged before when stories about my patients (and their families) appeared in local newspapers. But this time it’s different. This time, my patient is the author!Let me explain.Phil (he gave me permission to blog about this) was receiving radiation therapy at another institution. He was suffering one of the common side effects – burning skin. Realizing that the redness and burning are caused by inflammation, he had a clever idea. With the permission of his radiation oncology team, he tried an over the counter anti-inflammatory cream. It worked! His skin improved dramatically. Photo CreditThe best part is what Phil did with this experience. He didn’t just tell his treating team. He didn’t just tell his friends. He wrote a case report describing the experience, and with the ...

How long should chemotherapy be given for ovarian cancer?

Dr.Kattlove's Cancer Blog — Sun, 04 Oct 2009 21:24:00 +0100

It is hard to stop treatment when it has been successful. I once had a patient with colon cancer that had spread to her liver who responded so well to chemotherapy that after five years she was still in remission. She lived far away from my office and as she aged, became reluctant to continue the drug (5-FU). So we stopped. Within six months, the cancer reappeared and didn’t shrink when we restarted the chemotherapy. A few months later, she died.Did stopping the chemotherapy allow the cancer to come back? Probably not. Nearly every study of prolonged chemotherapy has shown that it stops working after about 4-6 months of treatment. Even if the cancer regressed or even disappeared with the chemotherapy, it will generally return whether or not the chemotherapy is continued. Still it is temp...

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Medical Wealth Transfer

CancerDoc — Fri, 25 Sep 2009 01:29:00 +0100

Something like 50% of Medicare health dollars are spent in the final two years of a person's life. What no one is really talking about is that, in order for the system not to become bankrupt, there must ultimately be a diversion of resources from the elderly to the young. Unfortunately, this is in stark contrast to the trends of the past several decades, where debt is increasingly being transferred to future generations. Not only have we overspent at the cost of our progeny in things like defense, our trade deficit and our overconsumption of material goods, but we have essentially placed our current health debt burden on subsequent generations.Unless something is done now, this will undoubtedly worsen as the Baby Boomers age. That generation, unfortunately, has shown some of the least prop...

The black and white of breast cancer

Dr.Kattlove's Cancer Blog — Thu, 24 Sep 2009 00:31:00 +0100

This study was reported in the September 20 issue of the Journal of the American Society of Oncology.What does this mean for black women in the U.S.? They probably do have a genetic basis for a more aggressive form of breast cancer since many of their ancestors came from West African countries such as Nigeria (although the actual country Nigeria may not have existed then). Their cancer contains hormone receptors more often than their Nigerian counterparts, perhaps because of the racial mixing associated with Blacks’ early years in the country. But they still have a problem that cannot be solved solely by gaining the usual access to health care that we hope for everyone in the U.S.Black women need to be super vigilant in getting screened and getting screened often (although no one knows i...

Do oncologists hasten their patients’ deaths? You bet they do – at least the good ones.

Dr.Kattlove's Cancer Blog — Wed, 16 Sep 2009 16:53:00 +0100

Many years ago, a patient of mine with widespread cancer could no longer be cared for at home. She had failed all treatments, the cancer in her bones was causing terrific pain and the family couldn’t deal with it any more, even though they had help from hospice. At this point the only way to control her pain would be with intravenous morphine, my drug of choice. And it worked. The problem was that she slept all the time. Eventually, she became too sleepy and her breathing slowed. Not wanting to be responsible for ending her life, I ordered a drug called Narcan, which reversed the effects of the morphine. Immediately she awoke, screaming in pain. We restarted the morphine and she went into a deep sleep and eventually died. There is no question that the morphine hastened her death. Was it ...

A Famous Parent

Doctor David's Blog — Tue, 08 Sep 2009 02:24:00 +0100

In the past, I have blogged about patients of mine who have made the news. This past week, while I was reading the newspaper before going to work, my eye was caught by an article in the Sports section about a man with a familiar name.(Note: All personal information in this post is also seen in the article in the Washington Post, so there is no violation of confidentiality. Also, some links will require a subscription to washingtonpost.com to see.)The article was about the head football coach at the University of Richmond, Michael London. The article spoke about Mr. London in glowing terms, talking about how he grew up in Richmond, played defensive back for the University of Richmond, and eventually became a detective in the Richmond Police Department’s street crimes unit.See the video he...

A Family Undertaking: POV

CancerDoc — Sun, 06 Sep 2009 04:16:00 +0100

I just saw one of the most riveting documentaries in my life. It is called "A Family Undertaking: POV". It is all about dying and the industry of death in this country. It follows a growing movement in this country that emphasizes "home deaths" and "home burials" as opposed to the usual affair that occurs in a funeral home. A brief history is given of the evolution of embalming and modern funeral procedures that started during the Civil War. Apparently, prior to this, as would be expected, when people died, their families at home often took care of the burial, providing whatever ceremony was consistent with the family's beliefs. Burials often occurred on family property. There was no embalming or embellished caskets and other funeral rites. Rather, it was more of a personal affair. Where f...

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Recharged

CancerDoc — Sat, 05 Sep 2009 22:03:00 +0100

It was difficult to return. I suppose this is what most people face as they get older. You get wrapped up in your job, your parenting, your social and religious roles in your community. You "become" someone. You have a persona. There are responsibilities and expectations. Much of this is a really good thing.But, in some ways, it can be oppressive. For the past few years, I have fully evolved into the role of an oncologist. I know. After 18 years of schooling/training, you would think that it was about time. But, after all of those years, learning side by side with other fledgling docs, there is a bit of groupthink and herd mentality that occurs. Only when you are thrust into the "real world", where your day to day is essentially similar to what it will be for the rest of your life that you...

How useful is cancer screening?

Dr.Kattlove's Cancer Blog — Fri, 04 Sep 2009 21:23:00 +0100

Well, if you ask around, most people think it is pretty effective. This week, in the Journal of the National Cancer Institute, researchers from Europe published some numbers on what people think. They asked residents of several European countries how effective they think are mammography screening for breast cancer and PSA testing for prostate cancer. Specifically, if 1000 people were screened on a regular schedule, how many lives would be saved?On average, most thought that around 50 lives would be saved for every 1000 person screened for either cancer. Not even close. The real numbers are these: If 1000 women over age 50 are screened for breast cancer every year, one life would be saved. This number would be lower if the women were younger (breast cancer occurs much less often in young wo...

Time to bury this treatment.

Dr.Kattlove's Cancer Blog — Fri, 28 Aug 2009 23:28:00 +0100

Many years ago, I cared for a 50ish man with colon cancer that had spread to his liver. He had a good response to chemotherapy for a while. The cancer shrank and he felt better. Eventually the inevitable happened. The cancer began growing again. Although I was ready to treat him with different chemotherapy, his family wanted a second opinion and took him to the City of Hope, a fine cancer institution just outside of Los Angeles. The City of Hope also treated him with chemotherapy, but infused the drugs directly into his liver. This approach has had runs of popularity but has never caught on. I had tried it a few times and wasn’t impressed with the results. It is complicated because a surgeon needs to put a small catheter into the artery leading into the liver and the catheter then needs ...

Therapeutic Cloning Takes A Big Step Forward

Doctor David's Blog — Fri, 28 Aug 2009 03:50:00 +0100

Leber’s Hereditary Optic NeuropathyLeigh SyndromeMyoneurogenic Gastrointestinal EncephalopathyWhat do these disorders have in common? They are all mitochondrial diseases.What is a mitochondrial disease? Mitochondria are the parts of a cell that are responsible for generating energy. Mitochondria contain DNA, just like the nucleus does. Mutations in mitochondrial DNA can cause them not to function correctly, and some of these mutations cause the diseases listed above (and others).When a baby is conceived, we think of the baby’s DNA as coming half from the mother and half from the father. That is true for the DNA in the nucleus, but not true for mitochondrial DNA. All mitochondrial DNA is inherited from your mother.As a side note, the fact that all mitochondrial DNA is inherited from the...

You just need to try harder.

Dr.Kattlove's Cancer Blog — Tue, 25 Aug 2009 17:17:00 +0100

What does it take to prevent cancer? We know some of this stuff – stop smoking, and live a healthy life style. One of the components of a healthy lifestyle is a healthy diet. But although we all suspect a healthy diet can lower your cancer risk, it has been hard to prove.Now we have some proof! About 15 years ago The National Cancer Institute started a study called the Polyp Prevention Trial. We know that polyps are the first step to getting colorectal cancer. So, if we can prevent polyp formation, we can prevent cancer.There were about 2000 people in the study. All had been diagnosed with polyps in their colon and these had been cut out. Half the patients (about 1000) were put on a special diet, high in fruits and vegetables and low in fat. The other 1000 people were told to eat whateve...

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Vitamin D in the Spotlight -- Again

Doctor David's Blog — Tue, 25 Aug 2009 03:55:00 +0100

This study supports that belief, and also strongly supports the idea that intervention in the health of a child can have profound implications throughout her life.Related Posts:Does Vitamin D Help Prevent Breast Cancer?Is Vitamin D the Wonder Drug of the 21st Century? (Source: Doctor David's Blog)

Time to Recharge

CancerDoc — Thu, 20 Aug 2009 17:04:00 +0100

I have a trip planned next week. Camping alone in the desert of New Mexico and parts of southern Colorado. I forget sometimes that my problems are small within the grand scope of life on this planet. Sometimes, the majesty of the West reminds me of the long view of nature and of the smallness of my own life.This past week was difficult. One of our practice's long time patients was sent to hospice with refractory lymphoma after years of battling her disease. In the stress of it, her husband of 30 years had a massive subarachnoid hemorrhage the evening after our hospice discussion. He was otherwise totally healthy. Within a week, their daughter lost both parents. A colleague of mine was diagnosed with melanoma. Early stage. She's only 33 years old. I think it will be fine. She's a triathlete...

When Translational Research Really Translates

Doctor David's Blog — Thu, 20 Aug 2009 02:45:00 +0100

All of us who work in a lab and see patients say the same thing: “I do this because I hope one day to be able to discover something in the lab that will really help patients.” This is the essence of what is called “Translational Research.”Our laboratory studies cancer stem cells. I have blogged about these cells before. Cancer stem cells are thought to be a small population of cells within a tumor that are resistant to chemotherapy and are capable of regenerating a new tumor. Thus, these cells are thought to be responsible for local relapses and for metastatic disease. Because they are resistant to chemotherapy, our usual treatments don’t get rid of them, so finding ways to kill these cells is critical to the further advancement of cancer treatment. There are many theories to exp...

Thank you, thank you!

Doctor David's Blog — Sat, 15 Aug 2009 22:20:00 +0100

How many of you have engaged in public speaking? You know, making a presentation to a large group of strangers. Did you ever have a nightmare about how things could go wrong?This past Tuesday, my nightmare came true.This past Tuesday I was invited to speak to the executive board of the Maryland Association of Student Councils (MASC). MASC represents all of the secondary schools in the state. Every year they choose a single charity to raise funds for. The amount they raise varies from year to year but is quite substantial.In order to keep my talk from being too "dry," I thought I would interview the parent of one of my patients. I asked her what it was like to be the mother of a child with cancer. I taped her son, who is VERY cute. Then, I created a powerpoint presentation that alternated i...

Even a few bad cells make a difference.

Dr.Kattlove's Cancer Blog — Sat, 15 Aug 2009 17:48:00 +0100

In the last few years, pathologists (doctors who examine cancer specimens under the microscope) have become increasingly expert at detecting fewer and fewer cancer cells. Using special techniques, they can find just a few cancer cells in the lymph nodes of women who have had breast surgery and lymph node removal.The problem has been what these few cells mean. Does it mean the cancer is more likely to come back and spread? Or, are they just some excess garbage that won’t cause harm?Now the answer is in. In an article published in today’s (August 13, 2009) New England Journal of Medicine, Dutch researchers have found that these few cells are bad news. Women who had them and didn’t receive chemotherapy (not the standard of care and as I said, no one knew what these cells meant) were 50 ...

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Controlling the Deficit

CancerDoc — Fri, 14 Aug 2009 01:16:00 +0100

I'm an Obama supporter. Let's just get that out of the way right off the bat. But, like many others, I'm a bit frustrated and confused by the "health-care reform" discussion that is going on in this country right now. It is complex, perhaps too far reaching and opaque. Although I support a single payer system, I'm a little skeptical about the government's ability to do anything correctly.Hopefully, with all of this rancor in these town meetings, there is now some increasing emphasis on the core problem at the heart of entitlement reform: that our country is doomed in the future if we don't control costs. Honestly, we need to reign in the cost of Medicare. That is just the number one priority for the fiscal solvency of this country. That is where Obama seems to have taken his eye off the ba...

Memory of An Elephant

CancerDoc — Thu, 13 Aug 2009 20:12:00 +0100

My thoughts drift back to my friend from prior posts, Elephant Number 5. That was her family's way of referring to her as the 5th daughter in their close knit family. She died three?, maybe four, five years ago now. It's funny how the time goes so fast. Sometimes, after seeing so many people pass into the hereafter, day after day, it is easy to get somewhat distanced from the pain, the personal journey of each patient. There really isn't time to mourn. The next person, the next chart, the next consult is a tragedy all on its own and requires your laser-like focus.That is often when Numero Cinco comes back in my mind. Because she was my own friend, who faced cancer early in life, beat it back for a couple years, was on the verge of cure, only to die of a complication of a bronchoscopy in on...

How much is a month of your life worth?

Dr.Kattlove's Cancer Blog — Sat, 08 Aug 2009 17:23:00 +0100

Let’s assume you have widespread lung cancer and your oncologist is recommending chemotherapy. She recommends that you also receive a non-chemotherapy drug called cetuximab along with the chemotherapy. She says that studies have shown that it adds another month to your life span. There are some added side effects, but these are manageable.Only one month you ask? Well why not. So plans are made for the treatment and then you get a call from you insurance company. The person on the line says although cetuximab is appropriate for treating your lung cancer, a course of treatment costs about $80,000. They make you an offer. Forgo the cetuximab and just take the chemotherapy and we will give you $20,000. Your family will have an extra $20,000 and, think, how important is that month?Now it is u...

Who Am I?

CancerDoc — Sat, 08 Aug 2009 01:24:00 +0100

I think a lot of my blogging lately is centered around some existential questions that have popped up lately. When I first embarked on this, I was confronted by so many issues centered around the nature of my future career/profession and all of the choices within. Now, I've chosen my life. It's been three years. I've settled into the meat of it. Like a marriage, the honeymoon is over. I'm beginning the cusp of the phase of it where I start to think about the rest of my life in this role. The oncologist. A lot of people died on me this past month. Two friends were diagnosed with breast cancer in their 30s. My relationship has foundered.My beliefs are shaken.Am I where I want to be? Am I going where I want to go? Who am I, when you strip away the accolades and the white coat and the test sco...

Our Water Footprint

CancerDoc — Wed, 05 Aug 2009 18:04:00 +0100

I've been thinking a lot about water lately, after I read in a magazine about the "water footprint", somewhat analagous to the carbon footprint that has become widely popularized as the population becomes more eco-conscious. We think about eating vegetables instead of beef, as the the carbon footprint of beef is much, much higher than fruits and vegetables... less fossil fuel needed to make the feed to give to the animals... less methane production from the animals... less issues with transport of product and refrigeration, etc. Therefore, beef is a bit less environmentally friendly than fruits and vegetables.Likewise, everything has a measurable water input. However, it is much less clear and less publicized. For instance, an apple may require several gallons of water to be produced. A pa...

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"I don't know how you do your job"

Doctor David's Blog — Wed, 05 Aug 2009 02:04:00 +0100

Most days, I love what I do.Today was not one of those days.Today I sat down with a 13 year old girl that I take care of, along with her parents, and we reviewed the results of her most recent scans. The news was not good. A month ago she had no evidence of disease. Today, there is a large mass on one side of her skull, a smaller mass on the other side, a dozen nodules in her lungs, and cancer throughout her pelvis, in both thighs, and in her arm. A mass near her left hip has caused what we call a "pathologic fracture," which means the tumor has broken the bone, causing a lot of pain.Needless to say, I made her cry. Her parents, too. They all know what this means. She told me she doesn't want to die -- she only wants to live. I wish I could help her achieve that goal, but I know I can't.So...

Beware of Epo

Dr.Kattlove's Cancer Blog — Tue, 04 Aug 2009 18:42:00 +0100

I’ve written about this before. Maybe I’m obsessed. According to a huge study just published, cancer patients are more likely to die if they have received the red cell stimulating hormone called erythropoietin (also darbopoietin) or Epo for short. The study was published by a group called The Cochrane Collaboration. This is a worldwide group of scientists who get together every so often to analyze a topic.The Cochrane Collaboration is named after Archie Cochrane, a Scottish physician who highlighted the need for looking at the effectiveness of our medical treatments. This is the same mantra espoused by President Obama in his quest to lower health care costs. His point, and Archie Cochrane’s also, is that many of the treatments we provide in medicine have not been assessed for their e...

Health Care Reform

CancerDoc — Mon, 03 Aug 2009 01:24:00 +0100

Congress is on break for a month, the so-called summer recess. As if they work particularly hard when they are there... anyway, this next month marks a very important point in the "health care reform" legislation that is going through both houses of Congress right now.From what I see and read of the proposals and the surrounding media coverage, it is not really clear to me that the American people really understand what is being proposed or what real reform requires.Let us briefly go over the acknowledged problem in the first place:1. America spends something like 15-17% of the Gross Domestic Product on health care2. Yet, despite this, our health outcomes are no better and, in some cases, worse than our industrialized counterparts in Europe and Asia.3. There are a lot of uninsured4. Entitl...

What's It All About?

CancerDoc — Fri, 31 Jul 2009 04:02:00 +0100

There is a creeping bias towards agnosticism, if not outright atheism, throughout most of modern science and medicine. I can say for a fact that most of my mentors in college, medical school and training were, for the most part, nonreligious, and sometimes, quite hostile to belief. I, myself, a child of physicians, grew up in a household where atheism was viewed through the prism of truth and science and religion in the realm of voodoo and blind faith. I must say that to this day, I remain deeply skeptical of faith, at least as it is promulgated by the Judeo-Christian-Muslim triumvirate. What the hell are we doing here then? It plagues me, torments me, affects every aspect of my being. I know that that sounds awfully melodramatic, but it's the truth. Maybe it's the daily existential crises...

The Hurt That Never Leaves

CancerDoc — Wed, 29 Jul 2009 14:18:00 +0100

It's been a pretty crappy week. Three years into full-time practice and it still gets to me when a patient dies. I know to the lay person that that seems appropriate, but there is a certain amount of detachment/PTSD/burnout/self-survival that occurs when you're knee deep in trauma of some kind, be it cancer care, war, police work, or any number of personally demanding jobs that are wonderful and horrible simultaneously.But, it's still gets me. Maybe too much. I've laid off the blogging for nearly two years to kind of get my bearings in full time practice. It's never pretty when idealism collides with reality, but I guess that's what "growing up" really means. It's not chronological, it's psychological. My last 10 days... a colleague, 32 years old, another doctor, was diagnosed with node-po...

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Team Sarcoma 2009

Doctor David's Blog — Mon, 27 Jul 2009 04:09:00 +0100

This weekend is the conclusion of International Sarcoma Awareness Week. We at Hopkins kicked off the week with our 2nd annual All Wheels Welcome ride down the Baltimore and Annapolis Trail. It was a marvelous event, with over 150 participants of all ages – including current and former patients, as well as their friends, families, and supporters. I think we were all amazed by Team Luca, the family and friends of a current patient of mine, who all showed up in bright red shirts and were an inspiring presence.I want to extend a personal Thank You to everyone who helped organize the event and to everyone who participated. We raised almost $13,000 in just one day. This year’s event was larger than last year, and we hope next year will be even bigger!The highlight of the week every year is t...

Reduce your cancer risk. Cut out the fat.

Dr.Kattlove's Cancer Blog — Tue, 07 Jul 2009 19:04:00 +0100

Yes, if you are fat, reducing your weight through surgery can lower you cancer rate. This was just announced in a study from Sweden where two thousand obese Swedes underwent bariatric surgery. Bariatric surgery is the kind where they reduce your stomach size by putting a band around it or where they actually bypass your small intestine so you can’t absorb food. The researchers compared the cancer rate in the surgery patients, who lost on average 45 pounds, with another two thousand obese patients who hadn’t had the procedure (controls). After 10 years, the cancer rate in the patients who had the surgery was one-third less than the rate in the controls.It was about 6 years ago when we learned that obesity causes cancer. The work was done mainly by researchers at the American Cancer Soci...

Did Michael die of a drug overdose? Perhaps it’ a case of too much of a good thing.

Dr.Kattlove's Cancer Blog — Sun, 05 Jul 2009 00:07:00 +0100

The good thing isn’t the drugs, but rather the laws and pressures around narcotic prescription. I know this isn’t about cancer, but guess what – we oncologists are, or at least used to be, the biggest prescribers of narcotics because often the last weeks or even months of many cancer patients tend to be associated with pain. There is no specific dose of an opiate. All these drugs, like morphine, codeine, etc. are derivatives or chemical cousins of opium. So they are technically called opiates. They work by suppressing pain centers in the brain. They also suppress many other things, including the site in the brain responsible for keeping us breathing. Because there is no specific dose, we give enough to suppress the pain. Some patients do well on a low dose of whatever drug we prescri...

More good news for childhood leukemia patients

Dr.Kattlove's Cancer Blog — Sat, 27 Jun 2009 17:55:00 +0100

I often tell this story to illustrate the harmful effects of radiation therapy to the brain. I treated a teen-age patient with acute lymphoblastic leukemia, the kind most common in children. The treatment protocol in those days called for radiation treatment to the brain, because chemotherapy didn’t penetrate into the brain very well even if it was given into the spinal canal. Past experience told us that without radiation to the brain, the leukemia could come back there. He was a very smart young man and told me that when he went to college he wanted to major in mathematics because he was really good at it. But, after his radiation was complete, he confessed that he had lost some of his math smarts and perhaps would settle for something less challenging, like becoming a doctor. I was bo...