Monday, November 22, 2004

Death of a Colleague

While attending a meeting recently I ran into a doctor from the university where I completed my medical oncology training. He filled me in about the professors we both knew, and then I inquired as to how an old pal from the fellowship years was doing - pretty routine chit-chat up to this point. The reply I got stopped me in mid-breath: "He died two years ago."

When an announcement like this touches the ears it instantly short-circuits the brain. For a brief moment one cannot make any sense of the information received. I understood what the phrase meant, yet was simultaneously puzzled, because it was inconceivable that my friend was dead. It cannot be true, I thought. Yet in some remote gyrus where maturity resides the shock was already processed, and waves of pain familiar to all who have received bad news began to vibrate through me. I was crushed by this news, and obviously wanted the details of his death.

I was told that my colleague, who had trained in medical oncology with me, had died of cancer after battling it for almost two years. My old friend, who had devoted his life to treating people with cancer, had succumbed to cancer. The irony in his story is almost unbearable - a doctor cut down in the prime of his career by same enemy he was sworn to destroy.

For the rest of the day I found myself unable to concentrate, as thoughts of my friend swept through my head. I was ashamed that I had not kept in touch with him over the years - he died two years ago, yet I never knew until today! I regretted not being able to speak to his wife, to comfort him in his time of need, to pray for him, to mourn him. As I reflected I kept thinking how unfair this death was - this man, a servant of those living with cancer, surely was worth keeping alive! Why was he taken so early in his life?

My ruminations then turned trite, as I declared "Why him and not me?" We were both the same age, and if oncologists can be stricken with a senseless death from cancer at any time, why was he chosen? A profound sense of awe came over me, a fleeting impression of the power and command death has over our emotions.

I was reminded that there is no easy way to endure the sorrow that comes with what is commonly called the "vicissitudes of life". It is certainly beyond my understanding. What does one do with this tragedy? How does one honor the memory of a colleague without descending into bathos?

I didn't brood on this question for long, for the answer to me was simple: go to work, and keep smiling. Do your duty, whatever it may be - and be glad that you awakened this morning in good health. Fulfill your mission in life - and delight in the wonder of it all. Remember your partner by doing his work, caring for patients as he would have continued to do, had he lived. Above all, spread a smile or two as you go about your day - it can lighten the load of those who suffer, your burden included!

Monday, November 15, 2004

New Treatment for Lung Cancer: A Hint of Good News?

Those of you who are familiar with the malignancy known as NSCLC, or non-small cell lung cancer, are well aware that patients with advanced stage disease or metastases have a dismal prognosis. Most studies with combination chemotherapy produce a median survival of 9-10 months and a one-year survival of 30-44%. The percentage of patients alive two years after diagnosis is 11-19%, depending upon the size of the study and other malleable variables.

Once a patient's disease is refractory to chemotherapy, that is, once the lung cancer begins to grow after a combination of two drugs have been given, "second-line" chemotherapy is often recommended. The agent used for second-line treatment is either docetaxel or pemetrexed, which both produce a similar response rate of only 9%. The median survival time with either drug, however, is 8 months and the one year survival is 30%, compared with 4.5 months and 11% for supportive care, respectively. Because of these statistics they are FDA-approved and in wide usage.

The results of second-line therapy, while appearing meager to the lay reader, are embraced by oncologists like a parent reuniting with a lost child. This should give an idea as to how awful the outcomes were prior to the release of these "modern" chemotherapy drugs, when largely ineffective agents were used. We therefore with gusto recommend chemotherapy to our lung cancer patients, automatically exposing them to all of its various annoying, humiliating and sometimes deadly side-effects - all for a few more months of life.

This is the background I took with me to New York last week, where I attended a lecture describing a pilot study for the second-line therapy of NSCLC. In this trial patients were treated with the esoterically named agents erlotinib and bevacizumab, given simultaneously. The results were eye-opening for me, as this new combination produced a 20% response rate, a median survival of 12.6 months, and a one year survival of 52%. Why are these data provocative to a medical oncologist? They appear to be an improvement, but what's all the hubbub over these agents with the tongue-twister names?

The answer is: erlotinib and bevacizumab are not chemotherapy drugs!

They represent a new class of anti-cancer treatment called targeted therapy. This type of agent blocks a specific molecular target found on the cancer cell, which then inhibits cellular growth and division (mitosis) and promotes programmed cellular suicide (apotosis), among other functions.

Targeted therapy compounds such as erlotinib and bevacizumab also have the advantage of not causing the distresssing toxicities of chemotherapy so familiar to us all: they do not cause hair loss, vomiting, anemia, or fatigue. Their side-effects for the most part are mild, and include rash and diarrhea (trust me folks, this is mild stuff).

So keep an eye out for more encouraging news about targeted therapy agents. I predict that their role in the treatment of cancer will expand tremendously over the next several years, and that their value will increase as they are used earlier in the course of a patient's disease. Let's hope I'm right!

Thursday, November 04, 2004

The Doctor Who Hated Cancer Patients

Gentle readers, may I share with you a curious phenomenon that I have observed in my practice of medical oncology? Although it sounds as hideous as it is strange, I have worked with several doctors who have such a nihilistic attitude toward the treatment of cancer that they harbor prejudice and ill will against their own patients fighting the disease. Fortunately such a breed of physician is a rara avis in the world of clinical medicine, nevertheless, it is distressing for me to have to work side-by-side with a referring doctor who is not on my side. How could any doctor not wish the return of good health to one struggling with cancer? Rephrasing the question, why would a purported healer denigrate my professional attempts at healing?

Perhaps by describing the three main species of medical misanthropes I have encountered, the reasons behind such immature behavior will become evident.

The Ignoramus: who specializes in professing no knowledge whatsoever of the proper diagnosis or treatment of cancer. By feigning ignorance, he can justify his decision to not evaluate symptoms or findings on exam that might lead one to suspect a malignancy. The Ignoramus is recognized by his utter lack of interest in learning anything new in my field; for example, if I were to announce to him that a cure for a deadly form of cancer has just been approved and is in my office, ready to be given to his patient, his response would likely be, "OK, well thanks for calling." How does this doctor advance his basic fund of knowledge if he cares little about what happens to his own patients? Is this an example of what they called "passive-aggressive behavior" back in freshman psychology?

The Pessimist: always scanning the blue skies for that tiny black cloud which will give him the pleasure of proclaiming the day is going to be ruined by rain. The Pessimist just can't accept the fact that some modern cancer treatments are costly, that they work only temporarily, that they prolong life in less than all patients, that they do not come with a guarantee of success. Hey, for crying out loud- we oncologists realize we have a long ways to go - last time I checked I didn't see that coronary artery disease was cured, either! I find I must always quote survival data to this doctor in order to receive his blessing of approval prior to my involvement in a case, as if there are no other possible benefits to treatment. There's no quicker way to disappoint The Pessimist than to call with good news, because in his melancholy world cancer is a disease that is better left untreated.

The Sadist: the less said about him, the better. I know it seems unfathomable, but there is a species of doctor who delights in the misery of his patients. He expresses this subtly - by his demeanor, his body language, his choice of words - all designed to inflict emotional harm on the patient and especially the family. He never fails to illustrate how much of the patient's suffering has been caused by the oncologist's treatment. I therefore spend much time trying to rally again those dejected and depressed by cancer, and then by their doctor. Maybe this behavior is just an example of schaudenfreude unchained, or maybe it is simple revenge for perceived past injustices. Whatever motivates him, I can state with great confidence that my success in dealing with The Sadist lies in avoiding him as much as possible!

Could it be that I'm just too sensitive, that in any medical profession we must be ready to battle wits with skeptics, worrywarts, killjoys and jerks? Fine, then let us have at it - I will gladly lift up my smiling sword of hope against the frowning Dr. Scoundrel! At least I'll know whose side the patients will be cheering for.