Dr. Len's Cancer Blog

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Dr. Len's Cancer Blog

The American Cancer Society

Philip Morris Moves On, And Millions Will Die

by Dr. Len January 30, 2008

I can’t  get my mind off an article that appeared yesterday on the front page of the Wall Street Journal.


The headline is pretty straight forward: “Philip Morris Readies Aggressive Global Push.”


The content is close to as scary as it gets.


Attached to the article is a smiling picture of the soon to be anointed head of Philip Morris International, a gentleman named Louis Camilleri.  I suspect he is smiling because he is probably going to make a ridiculous amount of money.


To me, Mr. Camilleri is the next generation of the merchant of death.


For those of you who don’t follow these matters, allow me to enlighten you. 


Philip Morris, a/k/a Altria, is about to unleash its international division as a separate company no longer affiliated with its United States counterpart.  The sick part of this transaction (they let go of Kraft Foods a while ago, so we no longer have to mix Oreos with cigarettes) is that Wall Street and investors world-wide are literally salivating at the prospect.


Why, you might ask?  The details are nicely outlined in the article. 


Let me provide a couple of quotes:


“The separate entity, for example, would be exempt from U.S. tobacco regulations and out of reach of American litigators.  Importantly, its practices would no longer by constrained by American public opinion, paving the way for broad product experimentation.”


Or, try this:


“The move (to separate the international division from the United States parent) will make it easier for the tobacco behemoth to market an array of new smoking concepts, each targeted to different foreign populations, who, collectively are expected to smoke 5.2 trillion cigarettes this year.”


Here is another quote of interest:


“With some 350 million smokers, China has 50 million more cigarette buyers than the U.S. has people, according to Euromonitor.  Its booming tobacco industry, which the government says generates around $30 billion in tax revenue in 2005, is a pillar of the economy.”


I could go on, but I suspect you get the picture.  Since they can’t get away with their tactics as much as they used to in the United States, the tobacco companies are going to try to kill as many unsophisticated people as possible throughout the rest of the world.


There is another piece to this story that is equally disturbing to me.


I will admit to being a capitalist.  I know that capitalism doesn’t always work the way we would like, but compared to other systems that have been tried, I believe it is the best one available to provide incentives to ordinary people with innovative ideas.


That said, I will admit that I spend time reading relevant newspapers, magazines, and watch business news channels on a fairly regular basis.


What I have read and heard recently is nothing short of appalling.


For those of you who follow these things, you know that this country (and perhaps the world economy) is either in or headed for a likely recession.  When that happens, the investment cognoscenti try to reposition themselves in what they call defensive stocks.


If you listen to the talking heads long enough, you realize there isn’t much they usually agree on.  But there is one consistent message, repeated time and again: Altria (the company that produces Philip Morris’ cigarettes brand such as Marlboro) is as sure-fire an investment as you can make in these difficult times.


Why?  Many of the commentators always say the same thing to the effect, “I don’t condone the product but I love the stock.  After all, smokers are a guaranteed product.”


In other words, if you smoke you are addicted and no matter how bad the economy may get—such as being unable to afford your house, your car, your medicines and maybe even the food you eat—you will still buy your cigarettes.


Oh, yes, they inevitably try to distance themselves from the killing effects of tobacco with soothing words to the effect that “this is business,” but the bottom line is still the bottom line: even without the Oreos, the tobacco companies will always make money.


For those of you who invest and don’t think you have Altria (ticker symbol MO) in your portfolio, or your mutual funds or index funds, I promise you there is a good likelihood with “general” investment funds (not those that are sector specific, such as a health care exchange traded fund) that you in fact are an investor in Altria.  Even the most well meaning organizations can’t avoid investing in this company, without invoking onerous restrictions on their investment counselors. 


The mutual fund managers can’t live without it or stay away from it, if they are going to provide you with a positive return on your investment in difficult times, such as what we are experiencing right now.


Let’s provide a context for what I am talking about:


Let’s pretend that homebuilders (a beleaguered lot, but that is not relevant to this example) went out and built homes with the following proposition:


We will build a house, but when it turns 30, 40 or 50 years old, there is a 50% chance the house will collapse and kill everyone inside.  In the meantime, we will make a lot of money building those houses, and whatever happens will happen.  It isn’t our fault or our responsibility.  Even if you take good care of the house we built, it has a 50% chance of falling down and killing you.


Sound preposterous?  Yup.


Unrealistic?  Nope.


That is exactly what the tobacco companies do. 


They produce a product that when used as intended addicts many of its victims by the time they are in their teens or early 20’s.  Those smokers face a 50% probability they will die sometime in the future as a result of their habit.  And those who (in a sense) are fortunate not to die of a tobacco-related disease will have a great deal of suffering with other tobacco-related illnesses such as emphysema and heart disease.


I can’t imagine that a rational investor would make an investment in a home builder with this philosophy.  But on Wall Street and Main Street, when they invest in Altria, they do exactly that every day and check the stock tables regularly to see how much money they made.


So, praise Philip Morris International and its wicked business savvy.  Invest like crazy, because you will make lots of money.  Ignore the moral hazard, and explain it away in the name of capitalism.


But while you are doing that, ask yourself why the tobacco companies can escape the same scrutiny and outcry that afflicts the huge athletic wear/sneaker manufacturer that was accused of employing child labor? Or the toy company that used lead paint that might harm children? Or the companies that manufacture their goods in China and pollute the streams?


Our priorities, my friends, are all screwed up. 


All of those issues I have highlighted are important, but none as important as the millions and millions of people throughout the world who will suffer and die because we turned a blind eye in the name of making money.


A commenter on my blog recently accused me of having “blood on my hands” because I won’t agree that we must mandate that people take vitamin D to prevent cancer.


Compare that to the blood on the hands of those who run these companies, and those investors that try to make a dime on the backs of intense human suffering.


To me, it isn't even close.

Filed Under:

Lung Cancer | Tobacco

Medicare Co-Pays: Mammograms Take A Hit

by Dr. Len January 23, 2008

An article and editorial in today’s New England Journal of Medicine puts the issue of insurance, access to care and preventive medical services squarely on the front lines of the health care debate.


In what is a deceivingly simple and elegant analysis, the authors show that in Medicare managed care plans, increasing insurance cost-sharing and copayments leads directly to reduced use of a clearly necessary and effective medical service, namely screening mammograms for the early detection of breast cancer.


The authors show that as co-payments and co-insurance for screening mammograms are implemented and increase, there is a direct correlation with fewer women getting this valuable medical service which we know can save lives.


And, to make matters worse, the women who were more likely to be subjected to these cost-management tools were more likely to be poor, to be black, and to be less educated.


This is exactly the type of situation that has led the American Cancer Society to make such a major commitment to educating the country about the issues surrounding access to and affordability of medical care in the United States during this Presidential campaign.


What the authors did was look at how often women from the ages of 65 to 69 in 174 managed-care Medicare plans (commonly known as Medicare Advantage plans) had recommended screening mammograms at any time in the preceding two years from 2001 to 2004. 


(It should be noted that the American Cancer Society recommends annual screening mammograms for women at average risk beginning at age 40.  The article incorrectly suggests that we make that recommendation for women beginning at age 50.  Also, the study looked at compliance with our recommendations at least once in the preceding two years, when we recommend that women have a screening mammograms every year.)


They found a clear connection between a number of factors and whether or not a woman had a screening mammogram.


First, they found that more insurance plans required a co-payment or coinsurance payment by their participants at the end of the study than at the beginning of the study (3 in 2001, and 21 in 2004).


8.3% fewer women in plans that had any cost sharing had screening mammograms, compared to plans that did not require cost-sharing or had a very low co-payment requirement ($10 or less).


The authors also point out that if a plan started a cost-sharing requirement during the study, the result was that 5.5% fewer women had a screening mammogram, whereas those that had no cost-sharing during the four years of the study saw an increase of 3.4% in the number of women who had a mammogram.


The bottom line: if you were in a plan with cost-sharing, the odds were 69.2% that you had a screening mammogram in the previous two years, but if you had no cost-sharing, the odds were 77.5% that you got the recommended mammogram, which studies show can find breast cancer earlier, when treatment has a much better chance of saving your life.


Those percentages may not seem like much, but when translated over hundreds of thousands—if not millions—of women at risk it means the difference in saving many lives.


And, it may help explain previous reports about the significant decline in screening mammography rates over a similar time frame.


There were some other interesting and perhaps disturbing findings in the study.


Black women and women below the poverty level were more likely to be in the for-profit plans than the non-profit plans.  And in the for-profit plans, there were more co-pays and fewer screening mammograms. 


This might lead one to question why the for-profit plans are more attractive to poorer women, but it may also raise the question if they understand what they are buying when they sign up.  It also raises the question why these plans are increasing copayments for this service in a population that is least able to afford to pay.


The end result is that even though this seems like a small amount of money for a very valuable medical service, and although studies show that women understand the importance of getting a screening mammogram, if you are poor and vulnerable even that small amount of money can make the difference in saving your life or increasing the odds you may suffer with advanced breast cancer.


[I think it is important to point out that the data suggest that black women had higher screening mammogram rates than white women and women of other ethnic groups.  Also, the overwhelming number of women were in plans that had no cost-sharing (518,122 vs.31,970 observations of 366,475 women over the period of the study).


I would also point out that the authors assumed an average price for a screening mammogram was $100 to $150.  Although Medicare managed care plans do not have to follow the Medicare fee schedule, under traditional Medicare the price is supposed to be close to $81.86 for a screening mammogram in a radiologist’s office in 2008.  Under traditional Medicare, a woman would pay 20% of that, or a little over $16 if she did not have co-insurance, or the entire $81.86 if she had not met her annual Part B deductible.  I would be concerned if private Medicare plans had co-pays over that $16 limit.]


In an editorial that accompanied the article, my colleague and friend Peter Bach, MD outlined the issues very clearly about why insurance companies want cost-sharing, and how that drives behaviors.  Theoretically, cost-sharing decreases the use of less valuable and effective medical treatments.  With rising medical costs, that is assumed to be a necessary strategy, and has led to significant increases in patients’ out-of-pocket costs over the past several years.


Dr. Bach points out that women understand that screening mammography is valuable, especially in the older population where the risk of breast cancer is greatest.  Even understanding that, if women don’t have the money they don’t get the mammogram.


We seem to be turning logic on its head when even small co-payments result in a measureable and significant decrease in the use of a desired medical service that is so cost-effective and saves lives.


We know that mammography rates are declining significantly.  There are likely many reasons for this.  Now we add co-payments to the list.


That fact has significant implication for traditional Medicare, as well as the Medicare managed care plans.


After all, almost all services in traditional Medicare have co-pays of 20%.  Some women have co-insurance to cover these co-pays, but a significant number do not.  And that likely means that many of those women who are poor are not getting mammograms.


We also know that race, education and socioeconomic status adversely impact health outcomes when it comes to cancer.  To be poor, black and or uneducated in this country means the odds you will die from cancer increase significantly.


The solution appears obvious: limit or abandon co-pays in both traditional Medicare and Medicare managed care for necessary and appropriate preventive medical services.   But that costs money and political willpower, both in short supply right now.


We know that we need to do something to improve the health of this country and the American Cancer Society has become vocal on access to health care, since it has such a substantial impact on public health and reducing the burden from cancer.


This study reinforces the Society’s efforts and those of many others to bring focus to this issue during the Presidential campaign.


We don’t suggest that we have the answers to the health cost and coverage dilemma.  But studies such as this one can only reinforce our concerns that those among us who are disadvantaged for whatever reason need better access to affordable, quality, evidence-based health care.


Cost-sharing is grounded in the belief, as Dr. Bach notes in his editorial, that patients should have some “skin in the game.”  Cost sharing gets us there, but when it comes to valuable medical services, it obviously gets us beyond “there.”


We need to understand that prevention and early detection counts, whether it be for breast cancer or diabetes.


Its time we had the discussion on the public policy front about effective ways to get us where we need to be.  This presidential campaign is the opportunity we need to hear from all the candidates what they would propose—in clear and honest language—to solve this dilemma.


From my perspective, after all, a woman’s life is worth a lot more than $16.

Filed Under:

Breast Cancer | Medicare | Screening

The Great American Health Check 2008

by Dr. Len January 18, 2008

Back in December when I wrote about my screening colonoscopy, I made some personal notes about what I thought was important with regard to getting healthy and staying healthy.


At the top of the list was the need to take individual responsibility for your health, along with having an identifiable source of regular medical care, such as a primary care physician.


This week, the American Cancer Society is urging everyone to take charge of your health by understanding what you and your family need to do to reduce your risk of cancer, and to stay healthy by sticking with healthy habits.


The Society’s Great American Health Check is designed to help you know what you need to know to do what you need to do to accomplish your goals to improve your health during 2008.


I have long been an advocate for people taking personal responsibility for their health, and developing healthy habits as the cornerstone for avoiding illness. 


I am certainly not alone.  The American Cancer Society, many other organizations and certainly the medical community have been delivering the prevention message for years.


The sad fact is that too many people aren’t listening.


Unfortunately, we can’t always protect ourselves by doing the right thing.  And, as I know from personal experience as a patient and a doctor, doing the right thing isn’t always easy.  It takes a substantial amount of commitment and personal discipline for most people to comply with all of the various key health recommendations.


What most people don’t know is that unhealthy habits such as smoking, lack of exercise, poor diet and failure to get appropriate cancer screening tests can influence up to 50% of the cancer deaths in this country.  To me, that is an amazing number.


Add to that the fact that much of the diabetes, heart disease and stroke in this country are also impacted by the same factors and you begin to get an understanding of why these recommendations are so important.


We can’t prevent every cancer, nor can we prevent every disease.  Even if you follow every recommendation you are still at risk of chronic illness.  But your chances of developing those illnesses—and the consequences they bring with them—are markedly reduced by a lifetime of attention to your health.


I know there are many people out there who think we have a pill to solve every problem.  Fortunately, for many chronic illnesses, we do have medicines that can help.  We can treat high blood pressure, and we can treat diabetes.  We can find cancers early, and in some cases we can find pre-cancerous lesions before they become malignant.


But despite all of the medical marvels, prevention is still the best way to go.  It is one of the best investments you can make.


Obesity, for example, doesn’t respond well to pills.  Obesity does increase your risk of cancer, heart disease and diabetes.  We have ever increasing rates of people in this country who are overweight or obese.  The end result is more chronic illness.


Treating the diseases that result from obesity is no simple matter. 


Take kidney failure, for example. 


Obesity can lead to high blood pressure and diabetes which if not controlled can result in kidney failure.  When kidneys fail, you end up tied to a dialysis machine and if you are fortunate you can have a kidney transplant which then means you need to take medicines to prevent the transplanted kidney from failing.


That, my friends, is no one’s idea of an enjoyable experience.  We are fortunate to have these treatments available, and sometimes kidney failure is unavoidable.  But many times it is preventable.  The large kidney dialysis building right in the center of my small hometown suggests that this is not a war we are winning.


If you avoid obesity, you significantly decrease your chances to becoming ill with these diseases.  You improve your health, you improve your life, and you can continue to function normally.


I started out my medical career as a medical oncologist. Later, I became a primary care internist because I believed that preventing disease was where I could be more effective.


I can’t tell you how many times I had conversations with my patients about what they had to do for themselves before it was too late.


Patients who were overweight, were smokers, had high cholesterol and hypertension, and did not exercise were the core of my practice.  Time and again, I would implore them to do something about their weight, their exercise, their smoking and their diet.


“Do something now, while you still can,” was my standard lecture.  “Once the horse is out of the barn, it is too late to prevent the problems.  And, if you become ill with a heart attack, a stroke or kidney failure you won’t be the same.”


Occasionally, someone would listen and take action over a sustained time that resulted in better health and better life.  Too frequently, however, people didn’t listen, and the inevitable happened.


Back then, when someone developed emphysema or had a heart attack or stroke, there wasn’t much we could do to help them.  It was difficult to see them not following my heartfelt advice, and it was more difficult to see them struggle with the results of their illness.


From that point forward, I realized that prevention of illness trumps treatment of illness.


But all the doctors, all the treatments and all the medications in the world can’t make you take prevention seriously unless you decide to do it for yourself.


So take some time today or this weekend or next week to go to the Great American Health Check website and take the test.  Find out what cancer screenings you need to get.  Find out what you need to do to improve your health.  Then go to your doctor with your list and get started with a program and a plan to do what you need to do.


In other words, make a commitment to take charge of your life.  It isn’t easy, but like I said before, it is the best investment you can make: an investment in yourself.

Judah Folkman, MD

by Dr. Len January 17, 2008

A giant in medical research has passed on.


Judah Folkman, MD, died Monday.  News reports suggest that a heart attack was the cause.


What is special about Dr. Folkman is that he embodied many of the scientific attributes that have helped move medical research and cancer treatment forward over the past several decades, and possessed many of the personal qualities that many of us admire.


I can’t say that I knew Dr. Folkman.  I knew who he was.  But other than being aware of his research and his reputation, hearing a couple of lectures, and spending a day with him a little over a year ago at an American Cancer Society function, I wasn’t someone who had worked with him, or studied under him.


You couldn’t help but admire his presence.  I don’t know what he was like when working in the lab, but spending that day with him in Florida last year was--in a word--fascinating.


His humility, his openness, his honesty and his personal warmth were magnetic.  Had you met him on the street, or sat next to him on a plane you would have had no idea that here was a man who was one of the few that had taken an idea, researched a concept, and developed a drug that is not only helping thousands of persons with cancer today, but has also given the gift of sight to many more who suffer from macular degeneration.


Dr. Folkman was an unconventional thinker, and that is a trait that we at the American Cancer Society have come to appreciate.  His unconventional thinking gave him an idea, and despite much skepticism and many barriers along the way, he continued fighting his fight.  Eventually, his concept grew into a mainstay of the concepts that guide cancer drug development today.


Dr. Folkman’s idea today seems somewhat simple, namely that cancers need blood vessels to grow, and if we block that process we can essentially starve the tumor or at least slow its growth rate. Go back a couple of decades, and they were heretical and revolutionary.


Dr. Folkman pursued his dream despite the obstacles. 


I remember a lecture he gave in Baltimore many years ago where he described the success in the lab with what he called “endostatin.”  But then there was the skepticism, since other labs announced they couldn’t reproduce endostatin.  The arguments became intense whether or not endostatin really existed, or was a figment of laboratory serendipity.


There were also proclamations that Dr. Folkman had discovered the cure for cancer, but he was not the one providing the hype.


That was the promise, and today the reality: the concept was valid, the drugs are real, and the benefits in cancer treatment—although perhaps not as much as we would like (yet)—are significant for patients with a number of cancers.


I next heard a lecture from Dr. Folkman a couple of years ago at the annual meeting of the American Society of Clinical Oncology (ASCO).  There were thousands of doctors in the room listening to Dr. Folkman give a lecture on his research.  He discussed a number of topics, including the ability to measure vascular endothelial growth factor (VEGF, which is the protein that stimulates blood vessel growth in cancerous tumors) in the blood of laboratory animals.


He showed the results of experiments where the researchers were able to find small amounts of VEGF in the blood, treat the animals before there was visible tumor growth, and have improved survival as a result.


Sitting there that day, it became evident to me that this is where the future of cancer treatment is headed.  Whether it be measurement of VEGF, or other proteins (known as molecular markers), we will eventually get to the day when we can find cancers well before the time we can see them or feel them, provide treatment, and potentially cure or significantly control the growth of abnormal cancer cells.


What I also recall from that presentation was Dr. Folkman’s comment about the phone calls he received from patients who were desperate for help, people who had been told there was nothing more to do for the treatment of their cancer or that of a loved one.


He also seemed to open the door to the audience to call him if they ever had a question, which to me was stunning.  After all, here was a world-class researcher—not necessarily a group of folks who are known to be easily accessible—who said to look up his phone number and call him when you need help.


I googled his name, and there was his phone number, right on the internet.


I gather from the press reports that this was indeed a real offer, not just one made to look good.  It was open, it was honest, and it was said with humility.  My sense was that here was a man who cared, who was willing to help.


My last contact with Dr. Folkman was in December of 2006.  It was at a small evening reception and a luncheon the following day for a group of men and women who are supporters of the Society.


Again, I was struck with Dr. Folkman’s humility and presence.  I don’t mind saying that he was a delightful person to be around over those 24 hours.


I had a chance to comment to the group about what Dr. Folkman meant to research, to the American Cancer Society, and to the people in the room.


The news today is characterizing him as a “maverick.”  But from my perspective, he was innovative.  Today, we would say that he could “think outside the box.”  Back then, he was probably considered a little bit “off.”


In basic science research, however, we need those mavericks.  We need those young scientists with the brave new ideas that can lead us to the next great discovery and the next great accomplishment.  These are the types of researchers that the American Cancer Society seeks to fund, since they will be the next Dr. Folkmans.


Judah Folkman embodied that spirit.  He served as an example that day of why we as a Society and the people who support us do what we do.  


We had provided early funding to Dr. Folkman to support his research when there wasn’t anyone else who would take the chance.  Years later, it had become evident to the scientific community that that investment had returns beyond anyone’s wildest expectations.


What made the moment human was the fact that here was a man who was telling his story, and sitting in the room were people who had benefitted personally from what he had done. 


I was aware of one couple whose child had responded to Avastin (the drug based on Dr. Folkman’s research).  I was able to introduce them to the researcher responsible for giving added life and hope to their loved one.


We all have heroes in our lives.  Our soldiers, our police, our firemen, the people who take bold actions at unanticipated moments are heroes, our parents, our families, our spouses who love us.


Dr. Folkman devoted his life to unconventional thinking, dogged pursuit of an idea in the face of substantial skepticism, and gave hope and life to many who never knew who he was or what he did.


To me and many others, Dr. Folkman was a hero.


May his family, friends and colleagues find comfort in his blessed memory.

Filed Under:

Cancer Care | Treatment

The Smoker In The Restaurant: The Smoker Wins

by Dr. Len January 10, 2008

There is no doubt left that second hand smoke is dangerous to your health. 


As a result, many organizations and individuals have worked diligently on several fronts to get state legislatures and local governments to pass smoke-free laws and ordinances. 


There is no getting around the fact that many of us have come to expect smoke-free environments where we work, where we shop and when we go out to eat.


So what happens when there is blatant violation of the law?


My wife and I found out this past weekend.  The answer, at least in Georgia: not much.


So, here we were this past Saturday—my wife and me—walking through our neighborhood mall.  We had just spent most of our day at a medical organization meeting, and decided to stop by to pick up a couple of things on the way home.


Then we went into one of the mall’s restaurants for an adult beverage and some time to just relax, talk, and basically take a break.


The place of our choosing was one of those trendy, upscale places that attract people much younger than we are.  You probably know the type of restaurant—spare furniture, lighting that is just right, servers dressed in t-shirts that say “eat” or “drink” on the front and “up” on the back.


And then we smelled it—the cigarette smoke.   We chose a table near the bar, but it was pretty obvious someone nearby was smoking a cigarette.  And, in our home state of Georgia, that is supposed to be a no-no. 


If that wasn’t enough, it was what we learned as the afternoon turned into evening that surprised us both.


In July 2005, Georgia enacted a no-smoking law for public restaurants and bars that do not limit their clientele to people 18 and over.   By most accounts, the law has been successful and restaurant owners and patrons have obeyed.  I have even heard comments from restaurant owners and managers that their business increased after implementation of the law.


This place we went to Saturday serves adults, young adults and children, so there shouldn’t be anyone smoking on the premises.


I spotted the offender, and told our server that we were going to move further away to try to get away from the noxious odor.  When we sat down at the bar for our beverage, I commented to the bartender that smoking in public restaurants in Atlanta and Georgia was illegal.


“Not in the bar,” he replied. Only in the restaurant.  People smoke in the bar area all the time, we were advised.


Wrong.  In Georgia, no smoking means no smoking in a public restaurant or bar except if they ban customers and workers under the age of 18.


And then the smoker walked over our way in search of a match for her next cigarette.  Fortunately, she didn’t take a seat next to us.  The servers complied with her request.


It’s what happened next that was the surprise for us.


We finished our beverage, walked into the mall, and decided to get a glass of wine at a wine bar across the hall from our first venue.  Maybe the atmosphere there would be more favorable.


We asked the servers there whether they permitted smoking, and there was a resounding “no.”  They advised us that it was clearly illegal to smoke in a restaurant or bar, and the most affirmative confirmation came from the young lady who served us our glass of wine—who admitted that she was a smoker.


And who should be sitting just a couple of seats down the way from us, but a server from restaurant #1, easily identified by her trendy “drink up” T-shirt.


She promptly told us that smoking was commonplace in the other restaurant.  In fact, she said, on no less than seven or eight times customers had called the police to complain about people smoking in the bar and restaurant.


According to our new-found informant—who told us that the smoke actually had caused her difficulty with her allergies—when they arrived, the police chastised the complainers, telling them that they had more important things to do, like fight crime, and then promptly exited without issuing a citation.


Well, so much for non-smoking laws if they aren’t going to be enforced.


I subsequently contacted a colleague from our South Atlantic Division of the American Cancer Society, who is located in Georgia.  She supplied me with information from our state government that was provided to restaurants in 2005 when the law went into effect.  And maybe that explained some of the problem with enforcement.


First, I confirmed that I was correct in my interpretation of the law.  The restaurant/bar should not allow smoking on their premises. 


In addition, according to the law, they aren’t supposed to provide any ashtrays for smokers.  The words from the “Georgia Smokefree Air Act of 2005: A Guide for Business Owners and Employers” says: “The owner, operator, manager or other person in control of the space must remove all ashtrays from any area where smoking is not allowed.”


The penalties for violating the law? “A person smoking in violation of the law will be guilty of a misdemeanor and fined not less than $100 and not more than $500.”


The Guide concludes, for workplaces that serve customers, that they should, “Advise staff to take reasonable steps toward implementation but to avoid confrontations that may result in physical harm.”


Conspicuously absent from the document is information on who to call for enforcement when there is a problem.  Nada, nothing.  Maybe 1-800-SMOKEBUSTERS could help.


In another document my colleague supplied me, which was a summary of the original legislation, it turns out that the State Department of Human Resources and the county boards of health “and their duly authorized agents are authorized to enforce compliance with this law and the rules and regulations.”


I can’t say that I have seen the Department of Human Resources police in my neighborhood recently, and I really doubt they make rounds on Saturday afternoon/evening.  Same goes for the staff of the county board of health.


So what do we do?


Atlanta is a special place to many people, including me.  Not only is it where I work and reside during the week, it is also the home of our national office of the American Cancer Society.


The mayor (who happens to be excellent, in my personal opinion) made it very clear recently how much she appreciated the presence of our home office in her city, and we are glad to be here.


Maybe Mayor Franklin can give the police a call and figure this out.  I realize it is important for police officers to spend their valuable time on patrol and devoting their efforts to things that need their attention.  I have respect and admiration for the job they do.  And, I can understand why this doesn’t rise high on their list.


But I also suspect a couple of citations to customers—with escalating fines—will quickly bring the establishment in question into line with the law.  After all, this is not just about comfort—it is about our health.


Hopefully, someone will get the message.  After all, if New York and Ireland can do it, why not Atlanta?


Maybe the next time we “Twist” into the fancy place, it will be a bit more comfortable for some of us who might otherwise like to patronize it.  (Yes, that is the name of the restaurant.  I had to figure out a clever way to insert it into this blog.)


It would be a sad day if the health of many—including people who work in these establishments—is sacrificed for trend or ignorance or lack of caring.


After all, if a restaurant flaunts their lack of concern about their workers’ and patrons’ health in the restaurant where you can see what is going on, you probably should be concerned about how careful they are preparing your food back in the kitchen.

Filed Under:

Prevention | Tobacco

A Friend Is Gone

by Dr. Len January 05, 2008

My heart is saddened. A friend has lost his battle with cancer.


My friend’s name was Ralph Rothwell.  He was in his late 50’s.  He died Friday morning from complications of his disease.


In so many ways Ralph was a special person.  And, in so many ways he was typical of the millions of people who have fought their own battles with cancer and have touched every one of us.


Ralph was an attorney who I first met a number of years ago.  He was obviously intelligent and capable.  He wasn’t a fancy person.  His office was modest, his staff very competent.  His counsel was steady, understanding and supportive.


I guess the best way I could characterize Ralph was that he was comfortable in his own skin.  He loved his wife, he was proud of his family, he enjoyed his friends, and he liked to play golf.  He wasn’t flashy nor did he seek the limelight.


It wasn’t until we had worked together for a couple of years and completed the business part of our relationship that he wanted to tell me something: Ralph was a cancer survivor.


He told me that about seven years previously he had been diagnosed with a chondrosarcoma, a rare form of cancer, in his shoulder.  He had undergone surgery and was cancer free. 


Ralph was very matter-of-fact about his diagnosis and his survival.  I had no prior inkling of his illness—he obviously didn’t advertise it, and he was certainly living his life as normally as possible as best I could tell.


Then, there was the phone call in May 2004. 


Ralph had been treated at a major cancer center and had regular follow-up exams, which included a CT scan of his shoulder.  He was going for his final examination before they were going to declare him cured of his disease and release him.


But that was not to be.  The scan was abnormal, and showed a recurrent mass.  Surgery had been scheduled. 


Like so many survivors, Ralph handled the situation straightforwardly.  It was another bump on the road, not to be taken lightly.  But, at the same time, it was not going to derail his life and his living life.


That was the start of a new journey in Ralph’s life that ended yesterday.


There was the shoulder surgery, followed by some preventive chemotherapy. Then the cancer recurred in the lung, and there was surgery to remove tumors from his lungs. There was another lesion in the shoulder that had to be treated, then more treatment for tumors in the lungs with a gamma knife, and then chemotherapy. 


Inevitably, there were complications from the treatments and the disease, and at the end there was no clear single event that one could point to and say specifically what ended Ralph’s life.


I guess what made Ralph so special to me was his incredible fortitude and optimism, not to mention an underlying sense of humor that persisted throughout his ordeal.


There was the occasion he wrote me shortly after one of his surgeries to share the inhumanity of hospital gowns, and the difficulty he was having keeping the gown in place while typing on his computer on his hospital bed with only his left arm to position the gown and the computer and his left hand to do all the typing (he was right-handed).


There was the also the inevitable insurance company story, when he had the second recurrence of his cancer in his right shoulder.


The doctors wanted to perform a procedure called radiofrequency ablation (RFA), where they would essentially try to destroy the tumor with a needle and energy waves.  In the past, amputation would have been only treatment available.  RFA would hopefully give Ralph the opportunity to save what was left of his shoulder as well as his arm. 


Time was short, since the tumor was growing.  If it got too big, amputation would be the only option.


The insurance company refused to pay for the procedure, and said that he should have the amputation.  They said that RFA was experimental and not covered by his insurance policy.  Without a clinical trial to demonstrate benefit, they wouldn’t reimburse the doctors or the hospital.


For obvious reasons, Ralph wanted to keep his arm.  Most important, he told me, was that although he was certain he could overcome the serious handicap resulting from an amputation, he really didn’t want to have to play golf with only his left arm.


A letter was written to the state insurance commissioner’s office, letting them know that RFA was an accepted medical procedure, and that there never would be a clinical trial performed where half the people had their arms amputated and half the people would keep their arms to see who which group would do better.


Within hours after the letter was faxed, the insurance company approved the RFA. 


Ralph kept his right arm, and continued to play golf.


And then there were the life stories that are so familiar to many of us who have family, relatives or friends who have died from cancer.


During this past year, Ralph knew his cancer was spreading.  The doctors recommended chemotherapy—despite the very slim chances that it would have any benefit.


Ralph’s daughter was getting married in October, and he wanted to be there—without the effects of the chemotherapy impacting this very special moment in his life.


The chemotherapy was delayed, the wedding was celebrated, and Ralph’s wish was granted.


He started the chemotherapy shortly thereafter, and the side effects were overwhelming with incredible fatigue and decreased stamina.  


He had made the right choice.


Many people are going to miss Ralph.  I will miss Ralph.  I will tell you there are tears in my eyes as I write this. 


I’m not quite certain why Ralph had such an impact on me.


Maybe it was the fact that he played an important part in my personal life at a very difficult time. Maybe it was because he embodied so many of the qualities that I admire in a person.

Maybe it was that despite the terrible tragedy that befell him, he never lost his optimism or his somewhat dry sense of humor.


As I said at the beginning, Ralph was a special person.  Although he was special, he was also so typical of the people we all know who, despite their personal tragedies, go on living until they can live no more.


Early Friday morning, Ralph could live no more. 


His blessed memory will be with many of us forever.

About Dr. Len

Dr. Len

J. Leonard Lichtenfeld, MD, MACP - Dr. Lichtenfeld is Deputy Chief Medical Officer for the national office of the American Cancer Society.