Thursday, March 03, 2005

Kicking Sand in My Face

The patient sat across from me in the room as I read the consultation report from her visit to the World's Greatest Hospital. She didn't look sick but in fact was suffering from inoperable primary liver cancer - a type of malignancy unresponsive to standard chemotherapy. Her tumor was so widespread as to preclude any attempt at eradication with modern treatments such as chemoembolization, therefore I had promptly sent her off to the academic cancer center to determine if she could enroll in a clinical trial. At the center they were offering treatment with a novel targeted agent, but there were no guarantees of response - the study was designed mainly to see if the therapy had any effect against the tumor.

The consultant had given my patient a consent form for the trial, but as I questioned her about it she gave me a determined look.

"I've decided against taking that treatment."

I asked her why and she replied that she didn't like all the testing that had to be done as part of the study. Although I was disappointed this seemed to be a legitimate reason. After all, who am I to push an experimental treatment on a reluctant patient? The only problem was that I still didn't have any recommendations for treatment that I felt even a modicum of enthusiasm for.

Just as I was about to launch into a discussion of the use of supportive care, she interrupted me.

"The doctor there said I could take some new kind of chemotherapy if I wanted to - look at the report."

I glanced down and realized I hadn't finished reading the final page. Sure enough, he had suggested treatment with a drug called liposomal doxorubicin. I felt a twinge of panic as I placed the chart on the stand. Liposomal doxorubicin? Why hadn't I looked into that? As I discussed the possibility of using this drug I felt like that 97 pound weakling in the Charles Atlas ads from long ago - a "skinny scarecrow" oncologist compared to the muscular professor from the mecca of medicine.

Still...despite my wide-eyed admiration of this sage and ingenious recommendation, somewhere deep in the vaults of my brain a skeptical neuron stood up and shouted for his comrades to awaken. Before my patient could even stand up to leave a spark appeared in my eyes and I began to rub some second thoughts about this therapy out of my chin. I told her I would consider giving her liposomal doxorubicin but first wanted to investigate its success rate. She agreed with this plan and arranged to see me in a few days.

No matter from which lofty peak a new treatment recommendation comes - even from Olympus itself - the doctor in charge of a patient's care is obligated to investigate said treatment to determine if it has been proven to be effective in clincial trials. This is called practicing evidence-based medicine. It is the polar opposite of the recommendation that starts out with the phrase "Heck, I treated a patient once with [insert dubious therapy here] and he did fine - lived for twenty years after that..."

Being a disciple of this evidence-based method of practicing I looked up the precious liposomal doxorubicin chemotherapy for hepatocellular carcinoma (it took me ten minutes just to type it into the search engine) and lo and behold! The agent has been studied in at least three clinical trials, and not only did the response rate range from 0% to 10% (trust me when I say zero percent response is not an auspicious beginning for a new cancer treatment), all three papers concluded that l. d. has no benefit for patients with liver cancer.

Now what we have here is called a failure to communicate...a showdown at sundown...a standoff between the expert opinion of The Professor versus the clinical evidence unearthed by the lowly country doctor. This is a tricky situation because it is generally useless to impugn an academic physician. Their lapidary reputation is impervious to one chip from the hammer of a 97 lb. oncologist. My strategy therefore was to use the same approach that has led to continuous success from the dawn of my career: I let the truth be my guide.

I had a heart-to-heart with my patient and explained that the drug in question simply has not been shown to provide any meaningful benefit to patients, despite being given to dozens of them. She understood completely and was actually grateful to not be exposed to a therapy that had such a meager chance of helping her. She left the office that day with a better understanding of the complexity of her illness, but as she turned at the door she replied:

"I'll be back next week to hear about what treatment you have found for me."

Yes, evidence-based medicine is a wonderful thing for doctors. It gives them the opportunity to strain the eyes peering at a monitor long after the Great Hunter has risen in the winter sky, to hear the night wind outside the window muss up the bald heads of trees, to see the night janitor walk into the office and ask:

"Doc, are you still here? Why don't you go home?"

That sounds like a wonderful idea - after this next abstract I will go.

I promise.


At 4:29 PM, Blogger poopie said...

You rock :)

At 7:11 PM, Blogger Sara said...

General note about blog: Great prose. That's the reason why I love coming back.

At 8:52 PM, Blogger Dreaming again said...

I admire that woman's hutzpah (is that how you spell that?) and I am glad she listened to you.
I am glad you listened to her.

What I found frustrating is the assumption on her part that you can find a treatment for her.
(especially since she's refused one you've already recommended but didn't want the necessary testing to go along with it)

Unfortuneately, not everything is cureable, and treatments are less than adequate,but our media has us, as a society convinced that the medical society could cure us all if they just would and if they don't, they are simply holding out on us.

I'm on an email list for Myasthenia Gravis and right now there is a discussion going on about the neurologists not caring enough to give them the right drugs to cure them. As if the doctor's are intentionally holding out the best treatment for their favorite or honored patients ...


At 4:15 AM, Anonymous dmaduram said...

Phenomenally interesting post.

As a med student, it's rather disheartening to see that friction exists between private-care and academic physicians. I wonder if this the norm or an exception...

At 6:47 PM, Blogger Doc NOS said...

I've seen this from the other end. Occasionally we get patients who are sent to us with absolutly everything done, all workup complete, and proper treatment instituted. The question then becomes 'what can I add?' Even when it shouldn't even be asked. The inclination is to keep adding in order to prove your worth. I think it's pretty well known that academic centers overtreat and overtest. Good thing you and your patient put an end to the madness.

At 1:27 PM, Anonymous Fluor said...

For "Dreaming Again" Chutzpah is how you usually transliterate that word from the Yiddish. But, I suppose Hutzpah would also work since transliteration is an open ended game. However, in either case, the spoken word begins with a gutteral sound. Not with how an English speaker would pronounce Ch or H. I guess it doesn't matter.

At 12:58 PM, Blogger jon said...

I was looking at your posts about cancer cervical and found a good article about the same cancer cervical info too...

God luck with it : )

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