abh

A = Ativan

B = Benadryl

H = Haldol

Once again, MD Anderson reveals its mettle as to why it's consistently rated the number #1 cancer center in the world. Why, you may ask? ABH. And what does ABH have to do with cancer? They offer this combo of three established and very unrelated drugs as a measure to control chemotherapy induced nausea. Ativan is an anti-anxiety medicine. Think valium. It's in the same class of drugs. Benadryl? Think the over the counter antihistamine drug that makes one sleepy. And Haldol? It's an anti-psychotic used in schizophrenia.

Put them together and what do you get? A helluva anti-nausea cocktail. Let me put it this way. After the last round of chemo, my brother didn't eat for 4-5 days, lost ~15 pounds, was horizontal the entire time and states that if he had been asked if he wanted to do chemo again, he would have flat out said NO. And that's knowing full well that refusing chemo meant death. That's how bad he felt. And after his second round? He answered the phone this morning after having 2 eggs for breakfast. Holy freakin' crap! These are the types of stories that make me want to be a physician now more than ever. And I want to shake the hand of the person who came up with the idea of using this cocktail because it works beautifully. Why it's not used more widely is beyond me.

outside the box

Most of my background is in cardiovascular and metabolic diseases. Cancer, I haven't a clue. But necessity is the mother of invention so I'm educating myself. Given my liberal arts background, I've never been one to see every detail as necessary. I'm much more of a big picture thinker. I assimilate. It's what I do. So when my brother started off treatment at MD Anderson, I felt he was in comfortable hands from a standard of care point of view. I walked out of the visits thinking, "this doc knows a helluva lot more than me" which is a good thing. I've had it be the opposite all too often and that's never a good thing.

As a physician, we're trained (supposedly) by two guiding principles.

#1 - First, do no harm. Very, very, very important. And it leads to the second principle.

#2 - practice what is dubbed "evidence based medicine". What does that mean? We only use what has gone through rigorous clinical trials and shown evidence to have an acceptable risk/reward profile. This is how drugs and therapies are approved and is the best system we have.

But what do you do when it's your brother's life you're fighting for? I trusted his doc on the chemo end. I could find no flaws in his logic. But what about so called alternative therapies? He didn't bring them up and shrugged his shoulders in response to them despite the fact that MD Anderson has a whole section devoted to ingestigating them. In a perfect world, there are no alternative therapies. There are those that work and those that don't. That's what evidence based medicine is about. But we live in the real world. Investors can't make money providing evidence that green tea can help with cancer. In no way am I critical of the pharmaceutical industry. They come up with some wonderful and creative treatments. But it'll only take one so far.

So we're left with less conclusive trials (usually epidemiological or observational) and as a physician, you're left with your two principles. Could this alternative therapy hurt? And what is the evidence that it might help? And that's what I've been spending a lot of my time on rather than studying. Which is an awfully long intro to this small study titled "Psychological improves survival for breast cancer patients: a randomized clincial trial." In a nutshell, this group took women with breast cancer and assigned them to psychological counseling plus the normal therapies or just the normal therapies. The group that received the adjunctive counseling survived longer. It was an extremely small study so by no means was it definitive. But the part that got me was an accompanying scathing editorial. The title says it all "Finding what is not there". They go on to find fault with the methodology of the study and rip it apart finally concluding it was a monumental waste of time.

Part of their critique of the methodology is valid but I suspect they're throwing the baby out with the bathwater. Saying something cannot be there because it doesn't add up is tantamount to idiocy. Don't believe me? Let me let you in on a dirty little secret. Drugs happen despite people, not because they make perfect sense. Let's take the statin drugs. You've all seen the commercials and probably know someone who's taking Lipitor. Best selling drugs of all time, period. They've reduced cardiovascular mortality substantially. Know what? They almost never happened. Two companies were pursuing them early on. The Japanese group pulled the plug on their program for reasons that weren't clear. It scared the bejebus out of Merck. They even flew over to Japan to try to find out the reason. No dice. Merck took a leap and went forward with what was then a controversial concept. Science sometimes requires that people move forward based on their hunch. If you wait for a definitive answer, you'll wait for eons. It'll never come. A leap of faith is sometimes required which is ultimately why I think our scientific culture is so resistant to outside ideas. They require us to expand our creativity and explore the obvious possibility that we don't know everything.

clueless

Things sometimes work out despite one's best intentions. I had exams last week (which explains my lack of posts) and I walked out of my neurology class with a big case of Uh-Oh. With my brother's noma, it's made studying a bit more distracting. Consequently, I got way, way, way behind. About 17 lectures worth behind. So in a week, I crammed away thinking I've got a decent grasp on the material. The day of the exam, I spoke with my brother and he had done a 180 degree turnaround. Little pain, appetite back and in much better spirits. I went into my exam with a much lighter heart. I walked out thinking I just may have failed the practical exam and I think I aced the written part. Eh, que sera, sera. Shows how much I know. 88 on the practical and a 79 on the written (class average is usually around a 79). Like a half court shot on the basketball court, I promise you I could not do that again......Except that I have to come the final exam.

I changed my answer on a whopping 10% of the practical questions. During each rest station, I'd go back, erase frantically away and change another answer. My the end of the practical, my eraser was but a nub requiring a second pencil for the written. I never, ever do that because in the past, inevitably I always changed it to the wrong answer. Consequently, I have a long standing policy to always go with my first instinct since it is usually correct. Not this time. I was so unsure and so clueless, I might as well have been flipping a coin. And the result? Everytime I changed my answer I got it right. Not a good precedent here. So at the end of the day, I'm actually left with a possibility at High Pass in this class despite having a complete and utter lack of comprehension in the material. If I knew what to study, I'd go gangbusters on it but I think I'll just act randomly since I haven't the foggiest. It seems to have worked out so far.

Remember this the next time you're in a doctor's office and they pause to think. They're probably frantically trying to remember some obscure piece of information that has escaped their recollection. I guess the take home message is that it's ALWAYS a good idea to question your doc because when we don't know, we have to come up with something that resembles our best guess.

But to top off the day with a third piece of good news, Rush is coming in concert again! And this time, I won't get behind (yeah, right).

health Wednesday

This video sums up pretty humurously (and sadly in a way revealing just how human the scientific process is) the notion of Fat=bad. It's from a documentary called Fat Head. I'll have to try to find the dvd.

interesting part II

There are two sides to every coin. And while the patient may not like to hear that their case is "interesting", I can assure you that it is a very good thing to have those types of phyicians in your corner. Take this video from one of my lectures as a prime example.

It's a very good thing that a neurosurgeon somewhere had the idea, "I wonder what interesting thing would happen if I stuck some electrodes here?"

interesting

"The interesting thing about your brother's case is...." Scientists and physicians use that word a lot. I heard it three times in a lecture the other day when a pediatric neurologist was referring to a 15-year old girl. I used it a lot myself. In a sense, it's what drives us to the field in the first place. We find these diseases and the workings of the body fascinating. It's a bit twisted when one thinks about it. We get excited about the unusual and morbidly abnormal. When your brother is on the other end of that word, though, it takes on a whole new meaning. I cringed when I heard him say it and I learned that the patient probably doesn't want to have their disease to be thought of as "interesting". But in the end, it's a good thing because it engages the physician to try to solve the problem. A necessary aspect of life.

one little victory

After a very long day at MD Anderson, the first round of chemo is done and in the bag. All in all, it was a wonderfully uneventful experience. Basically, a lot of waiting, see the nurse practioner, doc, pharmacist, some more waiting. The chemo wasn't schedule until 6pm and the thing takes ~8 hours in all. Fortunately, they got him bumped up and we started about 3pm. The chemo is suprisingly dull. Basically, they pump him full of saline, antiemetics (blocks nausea), a bisphosphanate (helps with the bone mets), and a steroid for a couple of hours. The docetaxel took 1 hour and then the cisplatin took 2 hours. Then they run some more fluids through him. We watched movies, talked, and just kinda hung out. You hear all these horror stories about chemotherapy but that still may come over the next few days. We'll see how he handles it. He passed the first part with flying colors. A lot of thoughts are swirling around in my head about the experience, both from the patient's and doctor's perspective but two things stood out today. First, it's a big headache for my brother and his wife to pack up from Dallas to come down to MD Anderson. There was some confusion about their daughter getting picked up from an extracurricular activity and I'm watching my brother lying in a hospital bed calling friends to try to get someone to pick up his daughter. And I'm thinking to myself, is it worth it? I pushed the hardest for them to come down here. And I pushed hard. So I feel in part responsible for that choice. I'm beginning to see the responsibility doctors carry. Not only are you implicitly in charge but most people want to trust their doctor. In fact, I've seen people stick with bad doctors because of some strange loyalty that they wouldn't tolerate in other relationships. But I thought back to our visit with the doctor earlier. He mentioned that they could get this treatment up in Dallas, too. So I challenged him on the fact that the course of treatment recommended up there was slightly different - still a taxol and a platinum - but different nonetheless. After being diplomatic (what is it about doctors never speaking even a remotely critical word about another?), his reply was finally that his choice was more aggressive. And that's why we're down there. It ain't easy. It's a right pain in the ass. But as I told the NP, "we ain't here for the customer service, we're here for the brains." I don't think she knew whether to take it as a compliment or insult. So we tolerate the bs because we want the most aggressive therapy that he can tolerate. The second thing that struck me was just plain odd. Normally, when my brother sits in one position for longer than 5 minutes, he's got to shift around due to pain. He was laying there, not moving, looking perfectly relaxed. He looked like I feel after a few beers. So I asked him what his pain was (the ol' 1-10 scale for pain management). Usually, he's about a 4 on good days. Bad days can hit 6 to 8. It was a 1 right then. I had to do a double take. He hasn't been a 1 since this whole ordeal started. My mom was just lamenting to me how he had changed his walk due to the hip pain. The doc had bumped up the extended release morphine and he had taken that about 20-30 minutes earlier. He had gotten really well hydrated. He had received acupuncture the day before. And then there's the psyche of finally starting treatment. Extended release morphine isn't going to kick in that quick by just upping the dose a bit. Getting 500ml of fluid ain't going to do it. So that leaves either the psychosomatic or the acupuncture. To paraphrase Bull Durham, "never screw with a winning streak." If it was the acupuncture, then friggin' stay with the acupuncture. It could be pure placebo. I don't care. Anything that takes a pain from an average of 4 (and that's a 4 on ER morphine, hyrdocodone/acetaminophen, and celebrex) down to 1....well, I call that evidence based medicine even if it's voodoo. Whatever works. He walked out without much of a limp at all and that was a great sight to see. I hope he tries it some more and the pain relief lasts long enough for the chemo to begin to do its voodoo. We could use a winning streak right now. And today we got one little victory to build upon.