June 23, 2010

liveblogging - restaging

restaging - the process of assessing the current state of the disease, often involves (re)assessing the size of the primary tumor.  The status of pain is also a good indicator.

8:30 pm Thursday
Chemo is done.  I have to say that my brother looks far better than the last round.  Don't know if that's because it's 8:30 pm rather than 2:30 am, the fact that he knows there's just one more, or the fact that the acupuncture did something different this time.  We'll see if that continues the next few days.  Only one more round to go.

1:20 pm Thursday
Chemo has finally started.  I guess I can't really call it 'liveblogging' when it ain't live but I've had a horrible time with their wi-fi.  None of our laptops would connect.  My son happened to connect his i-touch to text his girlfriend, though.  Hey, gotta keep one's priorities straight.

I hesitate to comment on the scans because I'm not sure I really understood the report.  That's a direct function of the doctor not even knowing what was in the report.  It looks like the peripheral lesions (liver, ribs, etc) may be going away.  In the bony structures, it looks like there is some healing....well, something is replacing the metastatic cells anyways.  Even fibroblasts would be better than carcinoma cells at this point.  The primary shrunk a bit more which is good news.  My hunch is that with the peripheral mets controlled, after the 6th round, the doc may go in with radiation to clean up the primary and secondary tumor in the chest cavity.  But we'll have to wait another 3 weeks before we get anything more definitive.

11:15 am Thursday
Just got out from the doctor and I learned another valuable lesson as a physician.  If you're covering for another doc while they're out on vacation, make sure to spend more than 30 seconds reading the chart.  I was, shall we say less than pleased at the guy filling in for our regular doc who was out on vacation.  He basically said, and I'm not kidding, "the scans look good and we're going to keep going with chemo."  When asked to define "good" he gave a rambling non-answer and handed us the preliminary path report.  After reading it once, I knew more about it then he did.  Pitiful.

10:30 am Thursday
Our appointment was at 9 am which means we're still waiting for the doc.  It's like a commercial for apple here.  The kid in the middle is my brother's and the one on the left is mine.

4:30 pm Wednesday
Here's his third eye after acupuncture.  Funny side note.  I started to talking with the acupuncturist who happened to be a MD from China.  She was telling me about the different meridians and came to one near the shin that supposedly was associated with longer life.  I asked her if she utilized that point on herself.  Her response?  "No, I'm too lazy."  I guess both eastern and western physicians all take horrible care of themselves.

12:40 pm Wednesday
It's a bit like the military here.  There's way too much red tape.

There's a lot of walking from building to building (the place is massive).

There's a lot of hurrying up and waiting.  Everything seems to be running on time today, though.  We're waiting on his PET scan to finish and then we can grab some lunch before he goes to get his acupuncture session.

12:00 pm Wednesday
The chest x-ray is complete and now we're waiting for the PET scan.  For reasons that aren't entirely clear to me, he's not having a CT scan.  He's glad because that'd mean an IV.  He's sick of needles.  Here we are, me cussing at machines, because neither one of us can get our laptops to connect to their wi-fi.  I can see the router hanging on the ceiling 15 feet away and yet it won't connect.  So I adapt and go with the common use computers.

11:08 am Wednesday
Bloodwork is the only thing that moves quickly here.  He's done in 4 and a half minutes.

10:00 am Wednesday
We head down to the med center to get the bloodwork and imaging done in preparation of the doctor visit tomorrow.

6:50 pm Tuesday
Heading out the door to meet my brother and his wife halfway to Dallas. I then bring him back down to Houston to spend the night.

June 20, 2010

review - to kill a mockingbird

Synopsis - told in the deep south during the 1930s the book is both a story about loss of innocence as well as the racial inequities of the time.  The loss of innocence in part comes from the protagonist - a young headstrong tomboy dubbed "Scout" - her brother and their friend as they witness their dad's (Atticus) able but ultimately doomed courtroom defense of a falsely accused black man.  The three children believe in the noble spirit as well as the ability to always appear calm and right headed nature of Atticus, and so believe surely the man will get acquited.  He does not and is sentenced to die for his crime (sexual assualt of a white woman).  The courtroom tale parallels the childrens' own incorrect accusations towards a mysterious neighbor who ultimately saves their lives.  There is no happily ever after in this tale but it is not without hope.  One gets the sense that the children learn that life is brutally unfair yet there are good people in the world willing to stand up and do what's right.  And that someday, they will be the next adults who stand up to do the right thing.

Medical relation - I couldn't really tie anything into this medically other than the personality of the father, Atticus.  He's level headed and almost caring to a fault.  He defends the black man knowing full well the predetermined outcome but does so because he sees him simply as a human being, no different than anyone else.  Qualities for a good lawyer as well as a doctor.  The man reminds me a bit of my father now that I think about it.

Conclusion - I immensely enjoyed the writing style.  It's written in a southern prose which I've come to appreciate over the years.  The characters are extremely easy to relate to and as I read it, I could even picture the scenes happening in mind feeling like I knew the characters.  That's the mark of a good writer when it's like a movie playing in your head.  The other thing that struck me was how far society has come.  The book took place in the 30s and was written in the 60s.  Not exactly high points in society's treatment of people that didn't happen to have the right color of skin.  I look around my own life where growing up I had friends of every color and never thought anything of it.  Today I look at my class and again, see lecturers and students of every color and think nothing of it.  Politics aside, our president was elected without any issue of race coming up too overtly.  So while individual stupidity and racism will always exist in any society and any race, I think from a sociological perspective, our society has moved past the point of institutionalized racism.  That's a hopeful thing to know that things can change.  It makes me almost (but not quite) hope that we can correct our unsustainable path to health care that we're headed down.

June 16, 2010

thoughts from behind the mower

    Mowing yards?  It ain't exactly rocket science, or even medicine for that matter.  Your mind has a lot of free time to wander.  My dad, only half jokingly, says that he's not always sure if his will wander back.  The excessive Texas heat may have a bit to do with that.

     The other day, I've got the backpack blower on my back generating a hurricane of wind with about as much direction as one, too.  This ain't one of those wimpy household electric blowers either.  When this baby roars at full power, you can actually feel it pushing your torso back.  So it's rattling away on my back and the debris is going everywhere but where I want it to go.  I've got this engine vibrating my entire body and it's not doing a damned thing I want it to.  I begin to cuss this blower.  It's nozzle doesn't taper at the end so it generates all sorts of wind in all sorts of directions.  Like a chicken without its head, it's about as directionless.  And it's pissing me off.  Then, I start cussing the idiot who designed this monstrosity.  Obviously, they've never had to use their tool for an extended period of time.  I can imagine the engineer firing it up, measuring 80 mph wind and saying, "yup, that works."  And now I hate him, too.  But out of the blue, this story from one of Robert Fulghum's books comes to mind and I start chuckling to myself.  If you've never read him, I highly recommend any of his books.  He can say it much better than I so here it is:

In the Solomon Islands in the south Pacific some villagers practice a unique form of logging. If a tree is too large to be felled with an ax, the natives cut it down by yelling at it. (Can't lay my hands on the article, but I swear I read it.) Woodsmen with special powers creep up on a tree just at dawn and suddenly scream at it at the top of their lungs. They continue this for thirty days. The tree dies and falls over. The theory is that the hollering kills the spirit of the tree. According to the villagers, it always works.

Ah, those poor nave innocents. Such quaintly charming habits of the jungle. Screaming at trees, indeed. How primitive. Too bad they don't have the advantages of modern technology and the scientific mind.

Me? I yell at my wife. And yell at the telephone and the lawn mower. And yell at the TV and the newspaper and my children. I've been known to shake my fist and yell at the sky at times.

Man next door yells at his car a lot. And this summer I heard him yell at a stepladder for most of an afternoon. We modern, urban, educated folks yell at traffic and umpires and bills and banks and machines--especially machines. Machines and relatives get most of the yelling.

Don't know what good it does. Machines and things just sit there. Even kicking doesn't always help. As for people, well, the Solomon Islanders may have a point. Yelling at living things does tend to kill the spirit in them. Sticks and stones may break our bones, but words will break our hearts...

June 8, 2010

health wednesday

     The American Society of Clinical Oncologists is currently holding their annual meeting so there have been a couple of interesting to studies come out of it.  The first one has been plastered all over the news.  It's an interesting example of where a bit of luck is involved in the drug development process.

     Pfizer had been developing this compound for cancer that inhibited a particular protein called C-met.  It was also known to inhibit another protein dubbed Anaplastic Lymphoma Kinase but they didn't think that part important.  Let's just call it ALK for short.  Along comes a study out of Japan which shows that a small percentage of the lung cancer population has a mutation in ALK.  Oops, I guess that part may be important.  Pfizer recognizes the opportunity and begins to recruit lung cancer patients with this mutation which occurs in about 3-5% of the non-small cell lung cancer population (NSCLC).  They presented the Phase I results.  Keep in mind that Phase I results are usually about safety.  Any hint of efficacy, especially in cancer is like icing on the cake.

     82 patients ended up taking the pill twice a day.  The patients tended to be younger (50s versus the typical 70s), never or light smokers, and had already failed at least 2 different chemotherapies.  Of those 82 people, nearly 90% had their tumor either shrink or hold steady.  That's impressive in a Phase I.  That's impressive in this disease considering that a 15-20% response rate is the current going rate for initial treatment.  I'm not sure what is in refractory cases like these.  And to top it all off, the side effects were milder than chemo because it's a more targeted therapy.  But with anything, here are my caveats:
  • It's Phase I.  Who knows if this can repeat this dramatically.
  • It's Phase I.  Who knows what happens with chronic treatment.  Maybe there are nasty bleeding effects down the road.
  • It only apppears to work in patients with this mutation.  I'm not aware if there is any response in people without the mutations.
  • I don't know if it matters for this treatment if the tumor is squamous cell or not.
  • We don't know what the long term effects are on survival which is where the rubber meets the road in cancer.
Pfizer is already lining up the Phase III trial.  I can't find anything on Clinicaltrials.gov but Pfizer's website has the criteria.  The patient has to have failed a previous round of platinum based therapy.  My brother hasn't done that so he wouldn't be eligible.  The comparator group also involves pemetrexed which works only in non-squamous cell so that makes me wonder about the histological diagnosis more.  Regardless, it's definitely on the top of my list to ask the doc during the next round of chemo in about three weeks.  It may be of utility down the road as I suspect if these results are real, then this will hit drug status fairly quickly.  Gleevec, another targeted molecular therapy that had impressive Phase I results like these, went from Phase I to bedside in about 3 years which is lightning fast.

science geeks have great humor

You can see more of this guy here.

June 7, 2010

review - the catcher in the rye

Synopsis - A precocious 16-year old Holden Caulfield is kicked out of yet another prep school and chronicles his several day adventure in New York.  Holden is at once rather mature for his years yet ill equipped to handle what it means to be fully human and all its foibles.  He borders on antipathy towards the entire human race (especially the 'phonies') while simultaneously envying the position of some.  It's written in a highly vernacular style and incidently was one of the most banned books from schools.  I can see why but that doesn't discredit its literary value.

Medical relation - In today's world, Holden would most assuredly be diagnosed with at least ADHD if not several other personality disorders.  Depression would probably enter the mix as he struggles with the death of his brother.  Addiction and an inferiority complex would also probably be bantered around for good measure.
     There's also a quote related to the title that while probably not intentional, made me think of being a physician.  Holden is speaking with his younger sister, one of the few people on the planet he admires and telling her about a poem by Robert Burns.  Of course, he's misquoting it and his sister corrects him.

June 3, 2010

liveblogging - a day in the life of chemotherapy

1:30 pm the next afternoon
30 some hours and over six hundred miles driving and the 4th round is in the bag.  Well, the hard part is just beginning for my brother as he has to endure the next 5 to 6 days.  But to hear the doctor reinforce that my brother had a "phenomenal response" makes it all worth it.  I'm going to sleep now.

7:30 am the next morning
Pull into Dallas 268 miles later, have a couple of eggs courtesy of my sister-in-law and back I go from whence I came.

2:30 am
Chemo's finally done.  Now time to pull the IV and head back to Dallas.

1:48 am
Hulu is great because there ain't much on at 1 in the morning.  Just watched The Simpson's listening to my brother snore away.

9:00 pm
I was always an advocate for open access to medical records.  I'm starting to realize why some doctors are hesitant to release their notes, though.  MDACC posts everything electronically.  During that 2 hour span in the waiting room with nothing to do but stare at the ceiling tiles, my brother asked me, "do you think Dr. XYZ would hold back some of the truth?"  I stared in disbelief because a physician not telling the truth goes against every grain of being a physician.  You see, the question was spurred by the radiology report from the CT scan 3 weeks ago which was very good news by the way.  The report, though, read like a medical report.  It's full of medical lingo, suggestions, thoughts, unknowns and interpretations.  After I read the first half, I turned to my brother and said "nothing new there to me."  I keep reading and finish it relieved.  Nothing there that's disturbing or with held by the doctor.  It's just that it was written in a foreign language and if you focus in on some keywords that are intelligible to the layperson, it can completely mislead the patient.  It caused needless worry in my brother's case and so I told him not to read them or if he did, have me read and interpret them.  I'm still a proponent of open records but I can definitely see how doctors would choose their words carefully knowing that a patient could see them.  It would perhaps behoove the physician to go over the report in person to avoid any misconceptions.  I'll have to consider that in my practice.  That and for the love of Pete, don't keep patients waiting for hours without end.

8:00 pm
Chemo started just after six.  I quick grabbed dinner at the cafeteria which consisted of a vegetarian lasagna and the rest of my brother's Blue Bell cookies'n'cream ice cream.  The anticipation of chemo sets in pretty quickly.  Call it a prodrome since so far he's received saline, anti-nausea meds (emend, zofran, dex) and the bone drug zometa.  He was only able to eat a few bites and then passed the pint onto me.  "Do you want to try some meditation or humor?"  The Office sufficed and after a few episodes of laughing at Michael being the obnoxious idiot, my bro's asleep.

5:45 pm
Still waiting on chemo.  Doing the math, if we get started at 6 (and that's a big IF) then we'll get out of here by 1 am to head back to Dallas.

4:10 pm
Doc was only two hours behind which is pretty much par for the course here.  Now we wait for the chemo to call his name to start the 7 hour process.  Note to self, need to look up the BATTLE trial as well as review the data on the MEK inhibitors as those are potential clinical trial options down the road.  The wait is bad but the opportunity for every possible therapy is top notch.  Give a little, get a little.

3:15 pm
PA says "what time was your chemo?"
"15 minutes ago"
"They gave your spot to someone else"
I love their humor here.

1:48 pm
Wow, we got into the room early and it's a different room for the first time.  No paint peeling on this door.

1:06 pm
After a last supper of steak, we're at MDACC waiting for the doctor's blessing that he's fit enough to undergo the next round of chemo.

11:03 am
Arrive for bloodwork to see if his white blood cells have recovered, mainly his neutrophils.  It takes all of 8 minutes which is the only thing here that moves quickly.

5:50 am

Out the door.

5:00 am
Up to drive north towards Dallas to meet my brother halfway (someone's bringing him down) and then turn around to head back down to MD Anderson.

June 1, 2010

health wednesday

Another not-so-sublte, thinly veiled attempt at trying to influence the health of those around me....

     If ever there was a panacea, exercise would probably fit the bill.  Ironically, it's probably also the hardest thing for a physician to prescribe.  Certainly it's well documented for its protective as well as interventional effects on heart disease and diabetes.  It's easy to see how exercise affects the heart.  The heart is a muscle.  Exercise trains muscle.  The heart improves.  It's obviously more complex than that but that it gets the point across.  But what about cancer?  Cancer is a different disease.  What in the world would training muscles have to do with cells who have gone malignant?
     There is data on exercise reducing the risk of developing cancer but that obviously doesn't interest me much at the current moment.  Those cows have already gotten out the gate.  Intervention is the more critical component here.  So what does the literature say?  I found some interesting studies.  Take this study looking at the effect of exercise on breast cancer patients after diagnosis.  This diagram pretty much says it all.

To those who don't like making graphs, let me explain it.  The vertical axis on the left is mortality.  The higher up, the higher the mortality rate.  Not good.  The horizontal axis on the bottom is time measured in years.  The three squiggly lines?  Essentially, you want to be in the line that's closest to the bottom because that means improved survival.  The study takes the women and divides them into three different categories based on METs (Metabolic Equivalence Task) which is a formulaic way for exercise physiologists to compare different exercises based on metabolic output.  A MET of 1 is what your body produces to sit there and keep breathing for 1 hour.  Walking leisurely is around 2 METs while a 13-minute mile pace for an hour expends around 6 METs.  The higher the number, the higher the intensity of exercise.  You get the picture.  If you want more information, click here
     So you can see the top squiggly dark line had less than 2.8 MET hours per week which means they didn't do much other than walk to their car or walk to McDonald's from their car.  The middle dotted line had 2.8 to 7.9 MET hours/week which means they had light to moderate activity.  They weren't couch potatoes but they weren't gym rats either.  And notice what a dramatic drop in mortality occurs with just moderate exercise.  At 6-years we're talking a relative 50% risk reduction in mortality.  That's nothing to sneeze at.  And what happens if you add more intense physical activity (not necessarily more exercise, just more intensity).  It's not crystal clear but the bottom dashded squiggly line seems to possibly indicate an even greater improvement in survival.  A similar study in JAMA back in 2005 found a similar protective effect with exercise but did not find a correlation between higher intensity and improved survival.  These incremental improvements usually take much larger and longer trials which don't tend to get answered until much later, if ever.
     Now the caveats.  These studies were only in women with breast cancer but  there are similar suggestive data in prostate and colorectal cancer.  The BIG caveat is that these studies weren't randomized.  What's that mean?  It means that it assessed people who voluntarily exercised versus those who didn't.  It didn't take people and say "you exercise, you don't."  Those people who voluntarily exercise also tend to have higher education and all the sociological beneficial trends that are associated therewith.  It may come down to something as simple as these people are better motivated to live and fight and are better equipped to do so (better medical access, better social structure, better informed, etc).  In the end for my brother, it doesn't much matter to me what the mechanism is.  He's got all those sociological factors in his favor so run with it.  Literally.  If exercise embodies some psychological/physiological will to live, then by all means exercise away.  Bottom line is that aside from improved quality of life, strength, etc., it appears that even moderate exercise may improve survival in breast cancer patients.

PS - In searching the literature for various cancer related topics, it seems to me that breast cancer seems to trump all others in breadth of trials.  That probably reflects better fund raising.  I remember the American Heart Association lamenting that the Pink and Save the Tatas campaigns did their job a little too well as heart disease still claims far more female lives than breast cancer yet women are far more educated with respect to breast cancer and relatively much less so with respect to heart disease.  They came out with their own Red Dress campaign.  It didn't work.

PPS - This blog was much easier to write after I went for my own run.  Physician, heal thyself.