Doing the Right Thing, One Day at a Time

As I write this column, it is Saturday morning of Memorial Day weekend. I have been at my office several hours working on patient charts and mapping out cancer treatment plans. This type of work cannot be done in the midst of a busy clinic day. Once I am done today, my radiation physicist will compute these patient plans. Then I will come back out later today or tomorrow to review and approve them so treatment can start next week.

Such is a typical Saturday morning for me. This is the tedious, mental work that requires me to be alert, focused, and very careful. Modern radiation treatment is highly precise, and the treatment is only as good as the planning process. If I don’t accurately target the cancer, it doesn’t get treated. And if I don’t carefully protect surrounding normal tissues, side effects can be worse. All of this takes dedicated, uninterrupted time. So, I am here at my office this lovely Saturday morning because, well, it is the right thing to do.

What does it mean to “do the right thing”?

A number of guiding principles come to mind. For me, the most important one is to take my time. Doing the tedious work on a Saturday morning or weekday evening. Spending adequate time with my patients. When I rush or get careless, I make mistakes. And by the way, we should acknowledge our mistakes and learn from them.

A second principle is: don’t do either more or less than required. Medically speaking. What I mean is physicians shouldn’t do procedures that are unnecessary just to pad their pocketbook. The flip side is also true: physicians should provide needed care even if they do not expect to be paid for it. Yes, there are times when this is not possible, but the concept and practice of providing charity care is part of who we are and what we profess to be as physicians.

Third, don’t be afraid to ask for help. I can provide most radiation-related cancer treatment in Lufkin, Texas, thanks to the fantastic equipment and personnel at CHI St. Luke’s Health Memorial. But there are rare or unusual cases where I don’t mind asking colleagues for assistance. It’s OK to pick up the phone and call my Houston colleagues if needed. In a similar vein, I tell my patients that I am not offended if they decide to seek treatment elsewhere. Patients need to be comfortable getting their care from me, and almost all are. Some physicians get all bent out of shape and act offended when someone wants to go elsewhere for care. They need to get over it and realize it is not about them. We are to serve our patients, not the other way around.

Fourth, treat everyone the same. What I mean by that is, each person has value, and that value is not based on their insurance plan. We shouldn’t let money dominate our decision-making.

Reimbursement for one’s work is important, but physician compensation comes with an obligation that an ever growing, younger crop of physicians seems unwilling to meet. We “old school” physicians often lament that younger doctors don’t view medicine as a profession. New medical school graduates view medicine as a job, with an employee, get-in-and-get-out, do-the-minimum mentality. Yet, they expect high salaries off the bat. What a shame! Sometimes the best payment is the heartfelt gratitude of a needy patient.

Each of us should strive to do the right thing, one day at a time, no matter what our profession or job.

A New Era of Cancer Survivorship

We are surviving cancer in greater numbers than ever!

The American Medical Association's new oncology journal, JAMA Oncology, presented encouraging statistics in their inaugural issue on how many of us survive cancer. Some cancers have seen a lot of progress over the last 20 years. For example, patients aged 50 to 64 years and diagnosed with colorectal, breast, liver, and prostate cancer from 2005 to 2009 were 39% to 68% more likely to survive than similar patients diagnosed between 1990 and 1994. The article also pointed out that certain subgroups - the elderly, and African Americans - are not seeing as much improvement. Disparities in healthcare remain one of our greatest challenges in the United States. I have addressed this previously, but for today, I want to focus on the survivors.

According to the American Cancer Society, nearly 14.5 million Americans with a history of cancer were alive on January 1, 2014, not including carcinoma in situ (non-invasive cancer) of any site except urinary bladder, and not including basal cell and squamous cell skin cancers. It is estimated that by January 1, 2024, the population of cancer survivors will increase to almost 19 million: 9.3 million males and 9.6 million females.

I recently spoke at the Polk County Relay for Life Survivor's Dinner, and this weekend will speak at one for Crockett/Houston County. American Cancer Society Relayers are passionate about the fight to end cancer and remembering loved ones lost to cancer, but they are equally passionate about recognizing and honoring survivors. If nothing else, these dinners remind me that survivors are the everyman. And as such, survivors want nothing more than to live their lives with cancer in their past, not with side effects or debilities that are constant reminders of what they have been through to get where they are.

For the field of oncology - the study of cancer and how to treat it - this new focus on what happens when we cure cancer is both refreshing and eye-opening.

What does it mean to survive? Surely it means more than just to live, more than just to carry on despite the hardship or trauma of cancer. Today, when you can buy survival guides for anything from zombies and global warming to ballroom dancing and Disney queue lines, we very much risk cheapening the word. And how about the "take no prisoners" approach of the reality television Survivor series? Being the last man or woman standing is not the goal, either. Cancer survivorship is about all of us reaching the goal!

I believe that successful cancer survivorship has much to do with attitude. I see it all the time. Patients with a positive mindset suffer less! Negative patients can talk themselves into any side effect and can let the burden of cancer treatment weigh so heavily on them that they simply can't function. Having strong support systems in place can help; surviving cancer is a cooperative effort which ideally should include not only the patient and the medical team, but the family, friends, caregivers, support groups as well.

We have entered an era where it is no longer good enough to cure cancer. We must cure with the least toxicity possible, all the while staying concerned with the cost of cancer treatment both for the patient and for society. And, we must ensure that these advances are available to all patients, regardless of race, ethnicity, income.

Are you or is someone you love going through cancer treatment? Get involved in Relay for Life! Survive? Thrive! Find an event near you at relay.acsevents.org.

New Cancer Fighting Technology in Lufkin

Last week, the Temple Cancer Center treated the first patients on our new Elekta Synergy linear accelerator, the first major investment of Memorial since the CHI acquisition. To say, "We got a new piece of equipment" understates the multi-year project of visiting other cancer centers, evaluating manufacturers, specking options, removing an older treatment machine and renovating the vault that houses the linear accelerator, and determining what other hardware and software is required to make this new piece of incredible technology work to treat cancer. No small task!

All told, this project, which also included a Toshiba large bore CT scanner, Vision RT image guided radiation alignment technology and other accessories, topped out at $4.5 million. It is a recognition of the importance of exceptional cancer treatment to our region and a signal that Memorial will remain the regional hub for cancer care in deep East Texas.

So, what does this new technology bring to our deep East Texas region? For our many patients currently being treated with IMRT - intensity modulated radiation therapy - we will be able to deliver their treatment in a fraction of the time it has taken up until now, often less than five minutes per treatment! Standard treatments can go even faster. And, these treatments are often even more precise with less dose to surrounding normal tissues, which will translate to even fewer side effects.

In addition, we will be able to implement a totally new procedure to the region called SBRT - stereotactic body radiosurgery. SBRT delivers high doses or radiation over very short courses - three to five sessions, typically - and requires much finer tuning and more rapid treatment delivery than we were previously able to do. We will start using this technology for small lung cancers first, but I anticipate over time treating cancers in other locations as well. The utility of the technology for lung cancer cannot be overstated. Lung cancer is almost always related to smoking, and heavy smokers often cannot undergo surgery, because they do not have enough normal lung function to survive removal of even a small part of a lung. However, these same patients can often be cured with SBRT. With low-dose CT lung cancer screening, we anticipate finding more early lung cancer; now we have the ability to treat them even if they cannot have surgery, with equal results and less morbidity.

Another site where we plan to implement stereotactic radiosurgery technology is in the brain, where small tumors can be ablated with radiation without having to be removed neurosurgically. Treating tumors such as these in an outpatient setting without having to resort to major chest or brain surgery is a remarkable benefit of this new technology. We will not start using this new technology immediately, however, because any new procedure requires establishment of appropriate protocols, quality assurance procedures, and training, all of which will be implemented over the coming months.

The Temple Cancer Center is also excited that our social worker, Appolonia Ellis, recently completed the Harold P. Freeman Patient Navigation Program, where she learned how to better assist our patients in accessing available services and programs so that they can successfully complete treatment. Patient navigation is fairly new to cancer programs, and we are excited to have the only navigator in the area.

At a time when other industries have announced plans to cut hundreds of jobs or move out of the area altogether, CHI's long term commitment to Lufkin and the Memorial system is reassuring. They are putting their money where there mouth is, so to speak. For that, I am grateful.

A Spoonful of Sugar

I don't think I'm unique in having a family that discusses medical issues at the dinner table. But in a family with a doctor, sometimes discussions – to the dismay of my children – are more colorful than they would like. I have learned (mostly) to keep discussions from veering off track. For my family’s part, they know there is a cardinal rule that must be obeyed: you are not allowed to mention Google or Reader’s Digest when discussing medical facts. That rule was recently broken by my wife, Catherine, but in an interesting and forgivable way. Here's the story.

My wife takes a potassium pill – a common supplement – once a day. As anyone who takes this pill knows, it is a big tablet. A horse pill, some would say. And because of that, she wasn't taking it reliably. Some days she could swallow it without too much difficulty, and other days she just couldn't get it down. If she tried a couple of times without success, she just let it go. That’s where Google comes in. In a worthy attempt to educate herself, she went online, researched the medicine, and found out why she needed it. Now, she is much more compliant... to a point. She won't take it if she is alone, because she doesn't want to choke on it.

When she told this story at the dinner table, she concluded, "Isn't that interesting?" To which I replied, "What is interesting is that you didn't trust that because the doctor prescribed it for you, you needed to take it." My daughter then remarked, "That's because a lot of doctors are quacks." So much for respecting the medical profession these days.

Of course, as a doctor's wife, Catherine very much respects the profession of medicine, and I had a twinkle in my eye when I "accused" her otherwise. My daughter's sarcastic analysis, however, did sting a little. Long gone is the era of paternalistic medicine, where TV doctor Marcus Welby, MD simply told his patients what was best and they complied without question. Now patients come to our offices telling us what is best and expecting us to comply. And front line primary care doctors are so strapped for time and paid so little for each office visit that sometimes it is easier just to acquiesce. 

Physicians must resist that temptation. Historically, perhaps it was appropriate for the family doctor to be paternalistic when he knew his patient so well – both inside and outside the office – and when he took care of the medical needs of the entire family. Too often today, the primary care physician is seen simply as the source of a referral to a specialist. The gatekeeper moniker was a kind way of referring to the physician whose true role was (as far as the insurance companies were concerned) to prevent specialist referrals rather than facilitate them. That is a far cry from the position of a genuine coordinator of care who manages the various specialists’ recommendations and knows all the medications that have been prescribed. Such coordination takes a great deal of communication not only among healthcare professionals but between the primary physician and the patient as well.

All physicians – not just primary care physicians – must work harder to earn the respect and trust of their patients. We must take the time to explain the interventions we recommend and the medicines we prescribe. Those horse pills will go down a lot easier with a little sweet talk and education along the way. And our patients will be happier and healthier as a result. Now, that's good medicine!

Cancer is a Global Problem

Tomorrow is World Cancer Day. We think we have a cancer problem in the US, and we do. But other countries, especially the poorer ones, are truly suffering. Two publications by the American Cancer Society - Cancer Atlas and The Global Economic Cost of Cancer (which I quote extensively) - soberingly detail the scope of the problem.

For example, 6 out of 10 cancer patients would benefit from radiation therapy (my specialty) in the course of their cancer treatment. However, about 20 countries in Africa do not have a single radiation treatment facility. And even when radiation facilities are available, as is the case in several countries in Africa and Asia, coverage is woefully inadequate. Ethiopia, a country of around 90 million people, is served by a single radiation treatment center located in the capital city.

Similarly, although morphine to treat cancer pain is plentiful, safe, and easy to use, millions of terminally ill cancer patients in Africa and Asia die in pain because of regulatory restrictions, cultural misperceptions about pain, and concerns about addiction. Eighty-five percent of the global population lives in low- and middle-income countries, but consumes just 7% of the medicinal opioids, like morphine.          

For the first time, research has shown that cancer has the most devastating economic impact of any disease in the world. The total economic impact of premature death and disability from cancer worldwide was $895 billion in 2008, nearly 19 percent higher than heart disease. And, that figure does not include direct medical costs.

Cancers of the lung, bronchus, and trachea account for the largest drain - nearly $180 billion - on the global economy. That's not surprising, given that smokers die an average of 15 years earlier than nonsmokers. Tobacco is predicted to kill seven million people annually by 2020 and eight million per year by 2030, with more than 80 percent of the deaths taking place in low- to middle-income countries. One-third of those deaths are the result of cancers. This is almost entirely preventable.

And it isn't just lung cancer. Despite the fact that most cases of cervical cancer can be prevented or treated effectively, 274,000 women die from the disease yearly. Approximately 241,000 of these deaths are among women in low- and middle-income nations. And then there's breast cancer, colorectal cancer, and on and on.

It seems like all we hear about on the global stage is HIV/AIDS and malaria (and, more recently, Ebola) - the so-called communicable diseases. But the economic loss from HIV/AIDS ($193.3 billion) TB (45.4 $billion) and malaria ($24.8 billion) combined is not even 30 percent of the economic loss of cancer.

Why should you care?

Put simply, the global cancer epidemic is huge and is set to rise, according to World Cancer Day planners. Cancer treatment and pain management for those dying of cancer are not political issues. They are global health issues which we in the United States, with our expertise and yes, wealth, can tackle better than any other country. They are also the type of moral issues which donors and politicians of every stripe can come together to address. 

This will require effort on the part of organizations like the American Cancer Society and other NGOs, but it will to an even larger degree depend on the leadership of the United States in organizations like the United Nations and the World Health Organization, whatever you think of them. And it will depend on you. Support the American Cancer Society and ACS CAN - the American Cancer Society Cancer Action Network - so that we can create a world with less cancer and more birthdays.

Recognizing Stages of Grief

My father recently passed away from pancreatic cancer at age 81. What a devastating disease! He lasted a mere two months. Thanks to attentive physicians and great hospice care, he was comfortable and at peace when he died.

For my mom, who was married to my father for nearly 60 years, grieving will be a process. In the medical field, we are taught to think about grief in five stages first described by Elisabeth Kübler-Ross in 1969: denial, anger, bargaining, depression, and acceptance. Watching my mom walk through my father’s diagnosis and death, I caught glimpses of many of these stages in her emotions and responses. It is important to note that these stages were never meant to be all-inclusive or rigidly ordered. Depending on circumstances, certain stages may be more prominent than others, or not experienced at all.

Denial is indeed often the initial response to hearing that you have (or a loved one has) a terminal disease. We just can’t believe it is happening, especially when the one with the diagnosis looks so well on the outside or doesn’t feel that bad. Unfortunately, denial can result in poor judgment. Luckily for my parents, any flashes of denial were tempered by solid medical advice and faith in their doctors.

Anger is one of those ugly emotions that can pop up at any time. But, it is one that is not difficult to understand. I typically see anger as a reaction because of dreams that will go unfulfilled. My mom was humorously a little miffed that my father didn’t make it to their 60^th anniversary in April. But anyone familiar with my mother knows she is too strong a Christian to be truly angry. Significant, unresolved anger can signal deeper emotional or spiritual needs that can affect everything from pain management to dying a peaceful death.

Bargaining is the most interesting stage to me. There is a deep desire in us to bargain as Faust did with the devil for something unattainable… in this case, a cure. Sometimes we bargain with God: “If only you would spare him, I promise I would do anything!” In the terminal cancer arena, this bargaining often takes the guise of a search for alternative, unproven “snake oil” treatments. (Mexico, anyone?) To my parents’ credit, they did not pursue futile, expensive elixirs or elusive cures.

Depression and acceptance tend to wrestle with one another, with melancholy eventually fading and acceptance gaining the upper hand. At least that is what we expect with typical grief.

My mother is a strong, confident woman. She held her head high at my father’s funeral and presided over the reception and luncheon with poise and grace. She so appreciated having her sons and relatives with her! I feared she might not do well by herself after everyone left, but she firmly informed me that she needed some time alone to grieve. For her, that was the right decision. She will cry; she will remember. But she will go on, I have no doubt.

Grief shouldn’t be buried. Tears are OK, even desired. However, debilitating, ongoing depression is not healthy. A minority of people experience a complicated grief that requires significant emotional, psychosocial, even medical support. Hospices are obligated to offer bereavement services for families of patients. What most don’t know is that you don’t have to have lost someone on hospice to join a hospice bereavement group! If you are grieving a recent loss and want to talk to someone or participate in a support group, contact your local hospice for help. You don’t have to grieve alone.

Living Between the Dates

As a cancer physician, reading obituaries is, unfortunately, part of my job description. I don't mean to be morbid about it. Not everyone who gets cancer dies from it - far from it. We cure two-thirds of cancer today. But we still have a long way to go.

I recently read my father's obituary. Oh, he hasn't died yet. My mother, you see, is nothing if not organized. So both of my parents' obituaries have pretty much been written for some time now.

Obituaries are fairly emotionless documents. They also don't often convey the true sense of who a person is. Usually, an obituary is a simple compendium of facts - dates - such as when a person was born and when they died. Others before me have said that what is important is not the date of birth or death, but the "dash" in between. That dash is what symbolizes who a person is, how they lived, what they accomplished.

My father just had his 81st birthday on Sunday. He has been working full time as a financial consultant at the same firm in Midland, Texas (RBC Wealth Management) for more than 48 years. That is a remarkable accomplishment in a field where jumping between firms is not uncommon. But loyalty was important to my dad, and to his clients. They knew they could trust him. His honesty and integrity were natural, unspoken expressions of his Christian faith. But that won't be in his obituary.

My parents love to travel, and they have taken quite a few overseas trips since he reached retirement age, even though he didn't retire! In September, my wife and I were able to go with them to Ireland on a fantastic trip. At 80, their vigor and stamina was amazing. Those two weeks together were so precious, even more so now in retrospect.

Just weeks after we got home, my father was diagnosed with pancreatic cancer. He had the usual tests and meetings with specialists to determine what, if anything to do. His liver is involved and his prognosis is quite poor.

I consult often with patients who are bombarded by well-meaning friends and relatives who think they know what is best and are, frankly, a bit too vocal with their opinions. Thus, seeing my father have to deal with the "You ARE going to MD Anderson, aren't you?" pretentiousness was particularly difficult. Those of you who want to comfort someone dealing with a cancer diagnosis need to learn simply to listen. Don't give advice, because 1) your story or experience is almost always irrelevant, and 2) you unknowingly aggravate the situation by making the patient feel guilty or second guess their decision. Please remember: It's not about you!

Ultimately, after much deliberation, my father opted for comfort care only. I am incredibly proud of the strength it took to make that brave decision. His cancer is not curable and his prognosis is less than six months under the best of circumstances. He chose instead to share quality time with friends and colleagues, with each of his three sons' families, and with his wife of nearly 60 years. What a blessing that time has been!

The apostle Paul wrote that he has fought the good fight and finished the race well. Thank you, Dad, for finishing strong. For demonstrating integrity and commitment in your work for more than 50 years. For your quiet faith, service, and generosity. For your love of family. For filling that "dash" between birth and death with a life well lived and memories we will cherish. Maybe we can insert that into your obituary!