2006/05/26

Rectal Cancer- do’s and don’ts


Locally advanced rectal cancers just aren’t approached the same way as their (higher) colonic counterparts.

When one is already having symptoms, the chances are pretty fair that the disease is advanced.  So, love yourself more & do your screening according to the guidelines.  If screening picks up a problem, see a multidisciplinary team.  You may not need all of the doctors and, if yours are any good, they’ll tell you what’s what.

Don’t go getting more of your gut scooped out than is absolutely necessary. Make sure that your surgeon is an experienced one.  Better yet, find a colorectal specialist or an honest-to-God surgical oncologist (so few!).  Don’t dismiss suggested radiotherapy & chemo just because all visible tumor can be or has been removed.  Think on the “microscopic” scale too.

When cancer treatments other than surgery are deemed necessary, the overall design is to optimize the odds for disease control in your favor.  Make very sure that the therapies you receive are up to current standards.  Rectal cancer recurrence is a nightmare.

Enough already with absurd & totally unnecessary tragedies!


 


Previous Comments


Combination of chemotherapy and radiation therapy might be the best strategy for rectal cancer.
Posted by Janet at September 28, 2006, 1:36 pm

In locally advanced disease, chemoradiation AND surgery. Surgery has not been replaced by other modalities in that setting.
Posted by oncodoc at October 1, 2006, 3:31 pm

my grandpa has colon cancer
Posted by Ebenezer Seasal Brown the 3 at February 12, 2007, 12:59 pm
 
 

2006/05/19

Auto-pilot


Its been a laid-back month, with no new difficult cases.  I'm in auto-pilot mode, or my version thereof.

Picasso on himself in '72
Picasso, Self-portrait
Am I the only one who's stalked by this job or is this, in fact, an occupational hazard?  Clinical insights choose the weirdest moments to pop into my head: while I'm driving, snorkeling, barbecuing, showering, even whilst reading junk.  Most anything can set off these digressions: flak jackets (how to hide ambulatory infusion pumps), LvB's 9th (gamma knife for acoustic neuromas), Kris Aquino's billboard (MR mammography for breast implants), fluorescent plankton (herceptin schedules in FISH+), Ronald Ventura (CT/X-ray correlations), etc.  It can get really tiresome.  Who wants to suddenly awake with the realization of the "right thing to do" for a specific patient— Eureka! — when one wasn't even conscious of any doubts?  Or require a TV set at loud volumes to fall asleep? Or host ASCO fora in your head on limb salvage for sarcomas… when Russell Crowe is about to brain the living daylights out of Commodus in Gladiator?

Jeez.  Smacks of a "Flight of Ideas" or some such DSM thingy.  Strangely, the complete reverse happens when I have a problem before me, as with crossword puzzles, a Windows crash, light fixture reassembly, cancers of apparently unknown primary, or impending C-P arrest. Then, the house could be on fire but I'd have to be carried out to notice it.  Needless to say, this is a trait that The Spouse would rather live without.

Oh, well.  Either I need a shrink stat or, perhaps, a prolonged vacation. Or maybe this is just simply the game I've played my life into.   Whatever.




2006/05/12

Pre-Med and Medical School

Again, the questions about pre-med and medical school life.  Was it painfully busy?  Were you cut off from old friends?  Do you have any regrets?

In a nutshell:  It all falls into place.

The good news is that its possible to be a part-time beach bum while doing fairly well in Pre-med & Med, to bake a doctorate and digest it too.  Life is not meant solely for academics, least of all while one pays no taxes.  So many other things to learn, experience, & do, both the worthwhile & the decadent, and too few chances to live it up yet still emerge unscathed.  (Ah, Youth!)  So, if you already have clear short term objectives, the following are tried & true tips learned from most remarkable family elders...
  1. Early Organization
  2. Strict application
  3. Discipline, discipline, discipline
...as paraphrased from snooty Latin (Plan like Caesar, etc) for this presumably limited, frivolous mongrel of a relative. Thank God that they'd put me through years of special lessons to enhance my "pedestrian capabilities", lessons I'd now add to the philomath's kit-- speed reading & comprehension. Thank God too that I'd kept that Stanford-Binet score close to my chest, because their low expectations allowed for self-study on marine-themed weekends.

The bad news is that in the clinical training years after medical school, scheme results aren't quite as sanguine.  True colors will then show, and in more ways than just a faded tan.  At the bottom of the clinical totem pole, both hands are tied by the insolence of disease, its disrespect for social schedules, but mainly by insistent conscience.

Dali, Still Life Fast Moving
Maybe its the day of your first normal delivery (with the baby narrowly missing the bucket).  Or when you first recognize a syndrome from separate clinical signs (oh, how sweet it is!)  Or even when you miss out on warm shock because you're just too focused on scut work (and you stop being in awe of your resident).  Whatever, the day will come when strangers' fates are undeniably in your hands.  Hoping to do a Pilate, the beached doc may yelp, "What the heck is this?!"  (Answer: the Practice of Medicine) but, inside of yourself, despite all procrastination, simply this:  Its Time.  After years of dodging it, you'll acknowledge your astounding ignorance with truest humility, and finally learn your craft.

2006/05/09

Fertility and Cancer Treatment


This month, the American Society of Clinical Oncology (ASCO) published its guidelines on fertility preservation in the blue journal. No surprises here but, in the age of evidence-based medicine and net-surfing patients, its a good review to quote, at last.

Back in the days before high-dose treatments were locally available, one had to MOPP a relapsed Hodgkin's, resulting in a fair number of cures at the cost of almost certain infertility. It's one of life's stranger ironies that these patients were largely good-looking young singles. You learned to schedule a separate talk with patient & fiancee, (excluding family), to lay out the facts. Options were detailed before commencing cancer treatment– from adoption to cryopreservation.

These briefings were always more complex and emotional than the BiCNU side effects discussion with the parents of minors in a Neuro-Onco ward. ("Just save him.") Sadly, the personal costs were also less predictable for young adults.

**Thanks again to Mr Buck Cash for the use of his cartoon.


Previous Comments


Is is okey to a cancer breast cancer patient to be pregnant?
Posted by Fe at December 23, 2008, 1:10 pm

Hormone receptor-positive breast cancer patients give me nightmares when they plan to be pregnant within the first 2 years of diagnosis. Talk with your doctor– he/she will need to know.
Posted by oncodoc at August 15, 2009, 2:49 pm

2006/05/08

We need humor too…

In this job, its best to observe a new "advanced cancer" patient as he/she walks/is wheeled into an oncologist's room, before the first word even escapes one's mouth.  

Impersonal smile +  wide-eyed, frantically gesturing companion.  Its a safe bet that the patient doesn't know the diagnosis… or pretends not to.   Look only at the patient with high-tech, quick-booting tunnel vision.

Hostile patient + harassed companion.  Its early Kubler-Ross, so Dig-in-Your-Heels-Doc!   

Haughty patient and companion, with labs from several oncologists.  A shopper, but still similar to the above.   Consider the extemporaneous /numbers-crunching Brainy CEO manner, a la Clinton.  Still haughty?  Refer to a large U.S. Cancer Center.

Haughty patient and companion, with report from large U.S. center.  Patience is a virtue… Lawyers are expensive… Your mother will haunt you.  Pre-morbid condition beyond Kubler-Ross?  Turf to the Shrink.  Almost beyond human endurance?  Voila!  The Dunce mode.  (Pray that they go elsewhere.)

Anxious patient + anxious companion.  Very recently informed about the diagnosis.  Hoping for an error.  The Distant Relative mode– gentle, humorous, mildly familiar, occasionally gossipy.

Withdrawn patient + frowning relatives in single-file .  The relatives will decide and/or pay, but may be battling each other.  Pick out the dominant one, fast!   (The one everyone looks at when costs are mentioned.)

Impersonal patient + a gaggle of deferential relatives.  The patient is in control, probably much loved and/or a taipan.   The Professorial mode– with facts, evidence, and the stats…in color.  Print out nomograms!  Justify your listing of Office XP and LCD panels as capital expenses!  
A look of peace + teary-eyed companion.  The primary doctor has done a fabulous job.  The patient knows and accepts his/her fate.  Guard your heart, or you'll lose it.


Many thanks to Buck for the use of this Toon.  Check out his site: http://www.buckcash.com/

2006/05/06

Hidden Cost Variables in Cancer Treatment

Many times, a patient comes in simply to shop doctors/costs.  I used to be amazed when large differences were found, but the root cause may be one or more of the following:


DIAGNOSTICS:  Read up on what is absolutely necessary.
  1. Was adequate staging done?  Which tests were used?  Not all tests were created equal.  There is a sensitivity & specificity profile for procedures– some can detect abnormalities better & a few pick up only those likely to be cancer. Its ideal when the test does both.
  2. Immunohistochemistry.  They can tease out a specific diagnosis where simple microscopy fails & are sometimes predictive of response to a specific treatment.  Further, they may afford hints on the chances of aggressive behavior or relapse.  It may be risky not to do these tests when your doc deems them necessary.
  3. Tumor Markers.  Not always helpful.  Strangely, there are many patients who request them even when told that they add no information in their disease setting.
  4. FISH.  Only when needed.  These days, it’s commonly done on breast tumors that stain her2/neu +2 to predict benefit from anti-her2/neu "Herceptin" therapy. 
  5. Chromosomal analysis.  There was a time when we did this routinely for lymphomas, but that was in a Center were all treatment options were available to the patients.
  6. Gene arrays.  In my dreams, Oncotype-DX costs only 50 pesos to do.  As it is now, doing this test may finish off the entire treatment budget.
  7. Electron Microscopy, and other rarely needed tests usually used in difficult diagnoses.
SURGERY:
  1. Surgeon's Fee - Not all "cheap" surgeons are inferior.  Not all expensive ones are great.  Look into their training background, volume of cases for a specific operation, etc.   Whipple's procedures, for instance— a literal killer in the wrong hands.
  2. Operating Room fee.  Oh boy, this can be a shocker. 
  3. Anesthesiologist's fee
  4. Cardiopulmonary clearance.  "C-P clearance" is needed before major surgery.  This means more tests, but you'll avoid unnecessary problems from the surgery itself.
  5. Postoperative Course.  A rocky recovery phase can triple your surgery expenses. 
CHEMOTHERAPY:  Except for gynecologic malignancies, systemic chemo is handled by a medical oncologist, esp in mature cancer centers.  Where "adjuvant" or post-operative chemotherapy is known to be effective, you'd be wise to invest your resources to maximize the chances of cure.  It is more costly when the cancer comes back, in more ways than one.
  1. Type of Drugs.  Protocols aren't interchangeable  There should be significant benefits to justify cost discrepancies.  Ask the medical oncologist about "cost efficacy".
  2. Brand of Drugs.  Branded vs. Generics— the BFAD let them all in but there are few or no comparative trials.  Some doctors play safe & stick to brands they know inside out.
  3. Dose.  Now, why are so many under-dosed, even for those tumors where dose density & intensity is known to be important?  This is not the way to go!  In the curative setting, the "better safe than sorry" approach could work against you.
  4. Hospitalization.  Is out-patient chemo possible?  Most problems arise a few days after the procedure.  There are many complex multi-day protocols, though.
  5. Supportive Management. "The good news= no more vomiting.  The bad news= anti-vomiting meds can cost as much as the chemo."  "Less chance of infection & added convenience with Neulasta"… yeah, at only US$4000 per dose.  Ask about options– before shifting to  "Alternative Therapy"!
  6. Side Effects.  When serious side effects set in, you've blown the budget.  Look up "Febrile Neutropenia" & "Acute Renal Failure", for instance. If your oncologist is also an internist, then he/she can anticipate, minimize, then treat these conditions.
  7. Professional Fee.  Again, not all "cheap" med oncos are inferior, and not all expensive ones are better.  Fees may reflect a doctor's upbringing, ethics, & needs– rather than ability.
RADIOTHERAPY (RT):
  1. Machine.  Most definitely, radiotherapy machines have their differences.  Ask what this means to you in terms of efficacy, side effects, and costs.
  2. Professional Fee.  Ask about the "per diem", exclusive of what's directly paid to the facility for the machine's use.
  3. Dose.  How many cancer treatments?
  4. Type.  For example, for Gamma knife & X-knife radiosurgery (which is radiotherapy!), ask– "Is there a significant difference in aspects other than costs?"  The answer may surprise you.  Ask the same for brachytherapy vs external beam RT for prostate cancer.  Unlike IMRT for cancers of the head & neck, not all fancy options imply paradigm-shifting advantages.
  5. Supportive management.  Depending upon the type and target location of your radiotherapy, you may benefit from protectants (expensive!), feeding tubes, etc.
In the Philippines, (I’m told), just tell them what to do.  Stop confusing them with information and options!  But… therein lies a problem that only an informed patient can minimize.


Breast Cancer Therapy and Costs


About half of newly biopsied breast cancer patients always ask for detailed cost estimates for treatment.  (The luckier half simply say, "Just give me the best".)  It doesn't seem to matter whether they have insurance or not if their account is held by a local company. 

Costs. They nearly always frown when I say, "It depends".  That's understandable, I guess.  It seems that naming a figure gives comfort– but how can an oncologist honestly box a disease so heterogenous into simple numbers from the outset?  I have to bite my lip when told that, "Dr So-and-So says it costs only this much…"  No comment.  Even when a patient is wise enough to give you a working budget, one still has to wade through the variables to get the loudest bang for her buck.  Its tragic when a metastatic breast cancer patient comes to the Center, still on the Tamoxifen started after primary surgery, only to test negative for the hormone receptors on her mastectomy specimen.

This isn't the flu.  For breast malignancies, the positive biopsy is merely a first step.  Other than announcing the existence of the problem, it does little else on its own, & a responsible oncologist from any of the subspecialties still wouldn't be able to formulate a decent cancer treatment plan. 

Sadly, there's a persistent notion that the crucial remedy is a radical operation up front… that all else is extra or bonus.   Now, what impact would that have on a patient with liver metastases?  Shouldn't the money have been spent on something else? 

Paul Outerbridge, c.1937
Breast Cancer = "Multidisciplinary Management".

To all Shoppers:  Do yourself a favor and see a certified specialist.  Would you allow a general surgeon to excise a brain aneurysm?!  Cost is not the same as Value, and the best way to reconcile these two factors is to consult the specialists whose business is to do little else besides.

I wish all life were simple too.


2006/05/02

Terminal Cancer and Euthanasia






Leafing through an old keepsake catalogue from the Van Gogh Museum.  It was bookmarked at the "Raising of Lazarus" because, as remembered now, it reminded me of a Prof who could never quit. 

————-

Impending demise, or when the end is in sight.  This does not refer to all cases of far-advanced incurable cancer– just those unfortunates whose deaths are expected very soon.

After working all these years in this country, it still boggles the mind that many relatives AND doctors resist opiate therapy at that late stage. These well-meaning folk usually have an overriding fear of the suppression of breathing and consciousness.  Unfortunately, its the patient who pays the terrible costs of a terminal disease rampage.  Palliative care being within the spectrum of cancer treatment, its the patient who's prioritized, not the others around his deathbed.  So, unless the patient specifies otherwise…

Now remembering the first time that I gave a morphine drip laced with tranquilizers to alleviate the labored breathing of a lung cancer patient in Manila.  This was years ago, shortly after my return from training.  I discussed respirator support, advised the patient of its futility, and offered the alternative of symptom control through opiates at the price of its secondary effects.  He gestured his choices and, in no time, we had a signed living will.  He died the next day.  I then got a lot of flak from the relatives for my "overly frank talk", and from the doctors for "practising euthanasia".  At that point, I even had to go into the fine points about the differences between active and passive euthanasia, the principle of double effect, the uses of a living will, and the objectives of palliative care in the terminally ill. 

Luckily (for my peace of mind), soon after he was relieved of severe breathlessness and before he became comatose from lack of oxygen, the patient had actually spoken up to thank me.