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Dr. Len's Cancer Blog

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Patrick Swayze

by Dr. Len September 15, 2009

My blog yesterday about the miracles of survivorship focused on the happier news about the impact of cancer treatment.  The passing of Patrick Swayze reminds us all that the stories too frequently don’t have the ending we would like.


Even acknowledging that grim reminder, there is still much to be celebrated about what this man meant to so many not only as an actor, but as a cancer survivor as well.


Mr. Swayze made no secret about his diagnosis, and made no secret that he was going to do whatever it took to beat his illness.  He knew the odds were against him, but that didn’t take away his hope or his resolve to continue living his life.


I didn’t know Mr. Swayze personally, or even much of his reputation.  To me, he was a well known actor who had appeared in several highly regarded films.  But it soon became apparent that he was more than an actor.  He was devoted to his family and his friends.  He was a part of his community.  There was indeed much strength and meaning behind the celebrity façade.  His illness deeply touched those who knew him.


Then there was the battle he fought publicly and privately to live his life.  He continued his work as an actor in a television series, despite his illness and the side effects of his chemotherapy.


It is no secret that I was interviewed about Mr. Swayze several times during the early portion of his illness.  I distinctly recall one reporter asking for my comments about Mr. Swayze’s continued work.   The interview included details of what he was going through on the set while he was filming the television series.


Those details were sad to recount, and they were sad to listen to.  The nausea, the pain, the weight loss.  This was not the side of Patrick Swayze that was caught by the television cameras or the side that he wanted to present to the public.


My comments to the reporter were not dissimilar to what I wrote yesterday about Mr. Jobs. 


Despite his illness, despite his turmoil, despite his personal battle, Mr. Swayze fought to “go on”--not only with the show, but with his life.  My comment to the reporter was that as a celebrity, Mr. Swayze was a special person to so many of his fans and others.  More importantly, he was a cancer survivor who represented so many who had the same struggles every day, trying to do their best in the most difficult of situations.


When the interview calls continued as his illness progressed, I actually declined to say any more about what he was going through.  The need to respond to salacious details about how he dealt with his illness were—in my opinion—beyond what to me were socially acceptable bounds.  In the eyes of many, Mr. Swayze was a true icon, and there comes a point when everyone is entitled to some peace in their lives—the paparazzi and the reporters notwithstanding.


Despite his loss, in my mind Patrick Swayze is still an icon and a hero.  He is an exemplar for so many patients with cancer, who although they did not know him personally may well have had a close personal bond with his struggle and what he represented to them. 


I also know he will be long remembered not only for his acting ability, but who he was as a person, and how he bravely and defiantly kept moving on despite the odds, despite the pain, and despite the inevitability of his fate.


The thoughts and prayers of many are with Mr. Swayze’s family, friends, and legions of fans today as we mourn his loss.  But we should also  say a prayer of thanks for his being part of our lives—in times that were good, and in times that were not.


May Patrick Swayze’s memory be blessed, and may all of us share the message of the life he so bravely lived during his too short time on this earth.

Breast Cancer And Health Reform: Check The Numbers

by Dr. Len September 14, 2009

A recent dust-up over an ad that tries to make a simple statement out of complex statistics shows how difficult it is to have meaningful discussion and understanding in a sound-bite world when it comes to health care reform.


The ad, launched by the Independent Women’s Forum on August 18th, comes to the conclusion that because the five year survival from breast cancer in the United States is 83.9%, and the five year survival in the United Kingdom is 69.8%, 350,000 women in the United States “may not have survived if the US survival rate were that of Britain.”  The implication is clearly stated: “(T)hat should give American women serious pause before reflexively touting the glories of a government-run health plan.”


If only the numbers truly represented what we know.


The basis of the argument was an article that appeared in the British medical journal Lancet Oncology in July 2008.  The study was funded by the Centers for Disease Control in the United States and Cancer Research UK, both highly regarded public health and research institutions.  Their research was focused on trying to make rational sense out of various statistics about cancer survival throughout the world.


You can imagine that this was nothing short of a herculean task.  Different types of cancer registries, different reporting systems, different definitions, different rules for diagnosing cancer and many other factors figured into the mix.


The net result was a mind-numbing—but very laudable—paper that actually tried to show through some standardized process what the five year survivals were for patients initially diagnosed with several common cancers including cancers of the breast, colon, rectum, colorectal cancer, and prostate cancer.


The researchers also looked carefully at cancer rates in the United States, especially at the differences in survival rates among different states and between black and white populations.


So what did they find?


Actually, the numbers quoted above about five year survival are correct: the five year survival for breast cancer in the United States is indeed greater than it is in the United Kingdom.


But wait a minute.  Is that also true for other countries that have government-run health plans?  Uh, not really.


Canada’s numbers aren’t particularly worse than those seen in the United States, and clearly better than the breast cancer survival in New York City (77.4%). Japan doesn’t fair too badly either. And—horror of horrors—Cuba is slightly BETTER than the United States at 84%!!!! (In fact, surprisingly, Cuba also leads the pack on colorectal cancer survival in women and is second on the list for colorectal cancer in men.)


In fact, when you look at the overall numbers, there are other health care systems in the world that are universal that don’t do so badly when it comes to five year survival in comparison to the United States.  And there are some that do much worse.


Now, I don’t want this blog to be misused and misinterpreted, such as suggesting that I think health care in Cuba is better than here in the United States (although there is data that shows they spend a small fraction per person on health care compared to the United States and have a life expectancy that is almost identical to ours).  And I am not taking sides on the issue of whether a universal government run program does a better job than fee for service medical care.   That is a political debate, and I will let the politicians and the public work on that one.


But I do think that at time statistics can be used whichever way someone wants to use them.  You have to be careful how the numbers are presented, and the simple suggestion that taking one number (five year survival) times another number (the total number of breast cancer survivors in the United States) and coming up with another number (350,000 women) that suggests that many women would have lost their lives in another country because of their health system is in essence misleading and erroneous.


There are a lot of reasons that survival numbers for cancers differ among various countries and populations.  It is true that we invest considerably more than other countries on health care technology, and this does lead to more access to more services, some of which are related to the early detection and better treatment of cancer.  For example, if you detect cancer earlier, you may in fact detect more cancers than will actually cause harm to the patient (prostate cancer is the best example of this) and those cancers have to be treated. 


You can also “bias” statistics by diagnosing cancers earlier in their course, which has the net effect of adding in some part to an appearance of longer survival (called lead time bias) for some patients with cancer, when in fact their disease will nonetheless progress leading to death at the same time in the future that would have happened had the diagnosis been delayed to a later date.


The authors had this to say about the issue:


“Cancer survival is a valuable indicator for international comparison of progress in cancer control, despite the fact that part of the variation in cancer survival identified in this study could be attributable to differences in the intensity of diagnostic activity (case finding) in participating populations….If overdiagnosis—which depends on diagnostic intensity—is more marked in one country than another, then it will certainly be harder for researchers to compare incidence, mortality and survival in those countries.  But over-diagnosis has different connotations for health-care systems and patients. In each country, the health-care system will have to be funded, staffed, and equipped to cope with the diagnostic and therapeutic burden of all patients with cancer, however they are diagnosed.  The heath-care system must make provision accordingly, and monitor the outcome of that provision; cancer survival is one such overall indicator.”


One of my colleagues, Dr. Elizabeth Ward, who is an outstanding epidemiologist, recently made some interesting observations.


You can’t look just at survival, but must also consider the larger picture including death rates from various cancers.  According to Dr. Ward, death rates from cancer in the United States in 2004 for men and women were 147/100,000.  In Canada, the number was 135, and in Britain it was 133.  For breast cancer, the death rates in the United States were indeed much lower in the US (15.6) compared to Canada (17.6) and the United Kingdom at 25.4.


However, if you look at overall life expectancy, the numbers in the United States for men are 76 years, and 81 years for women.  Canada does better at 78 and 83 respectively, and so does Britain at 77 years for men and 82 years for women.


The bottom line?  Be careful which figure you choose before you start comparing one country to another.


Coincidentally, an article appeared in last week’s issue of the New England Journal of Medicine, titled “British Lessons on Health Care Reform.”


Needless to say, I suspect the Brits are a bit sensitive these days about all the bashing their national health service has taken from those in opposition to a single payer plan or public option as part of our health care reform proposals currently under consideration.


But it was the specific comments about cancer care that I found most interesting, and certainly relevant to this current discussion.


The authors point out that Britain has had to substantially increase its investment in its health care system, which is now 8.4% of their gross domestic product, compared to 16% in the United States. 


They go on to talk about the methods Britain employs to control costs, which relies in part on determining the amount of money a treatment costs relative to its benefit for the patient:


“Most of the debate centers on the concept of cost per quality-adjusted life-year-gained and on where the funding cutoff is set.  For instance, is an extra month of life for a patient with cancer worth $1000, $10,000 or $100,000?  Admittedly, cancer survival is worse in Britain than in the United States, where there are far higher numbers of cancer specialists, better access to novel therapies, and more widespread informal cancer screening, but it is unclear which, if any, of these factors contributes the most to this cancer survival gap.”


So there it is: an admission in writing in a respected medical journal that cancer survival in Britain is less than the United States.  But that’s not the whole story, since there are other countries where government controlled programs do a better job with respect to cancer survival, and surpass the United States in life expectancy.


Again, the purpose of this blog is not to tout one system or another.  Rather, the intent is to set the numbers on the table, have an honest discussion, and inform rather than scare and inflame.


I just wish my expectations of civil discourse over an important issue weren’t set at such a high level.

Filed Under:

Cancer Care | Treatment

The Miracles Of Survivorship

by Dr. Len September 14, 2009

A couple of conversations and a news story over the past week have led me back to an appreciation of the miracles and the problems of cancer survivorship.


The messages are mixed: we have accomplished truly remarkable advances in cancer treatment, but those advances come with unanticipated and very real side effects.


A former patient of mine tracked me down about 10 days ago.  He wanted to talk, and let me know about the recent events in his life.


The gentleman had Hodgkin disease at a young age, just when he was beginning to look forward to establishing his career and starting a family.  The disease was treated successfully with radiation therapy, and his course was—in general—uneventful.


Eventually I moved on and we parted ways.  In our conversation, I learned that he was successful in his career and his life. Then disaster struck unexpectedly. 


Playing a sport he enjoyed, he had a cardiac arrest.  The wonderful news in this part of the story was that a cardiologist was nearby, and my former patient was resuscitated.  Talking with him a couple of weeks after the event, he had undergone surgery and was recovering with no apparent ill-effects.


The reality is that we have known that radiation therapy used to treat Hodgkins disease puts long-term survivors at greater risk of heart disease.  The problem is that the patient and apparently his physician weren’t aware of that information and the recommended follow-up examinations.   


As I told my patient, no one can say for certain whether or not his particular problem was related to his prior cancer treatment or a more typical cause of heart disease.  The reality is that there are other significant causes of heart disease, including cholesterol, family history and other factors that sometimes we just don’t understand.


But we can’t ignore the lesson that we haven’t done a good job of letting doctors, patients and their families know about the long term effects of cancer treatment and what needs to be done to follow these patients.  We also haven’t done a good job of helping patients find this information so they can be informed and serve as their own advocates.  


The other experience—equally unexpected—was an email from the family of a young lady I first heard about a year and a half ago.


The initial call came from a very concerned relative. I didn’t know the gentleman.  He was referred to me by a good friend of mine who asked if I could give some advice and guidance to a colleague of his. 


The patient was this man’s sister-in-law.  She was in her 30’s and had just been told she had fatal liver cancer.  The family was despondent and desperate. A colorectal cancer, without apparent symptoms, had been diagnosed with spread to the liver.  A doctor told her the disease was fatal and that not much could be done.  The family was in obvious distress at the news.


I couldn’t promise miracles, but I did say that based on what he told me—and given her age and general health—she shouldn’t take “no” for an answer.  My advice was to at least consider chemotherapy, and get into the hands of a team that provided the latest treatments for cancer that had spread to the liver.  I couldn’t say that she could be cured, but there was a remote possibility that she could be helped.  It was certainly worth trying, in my opinion.


The news in this week’s email was wonderful: the cancer had responded to the treatment, and the woman was now cancer free.  He thanked me for giving the family hope, at a time when hope was in very short supply.


You can share this remarkable story.  It is now being featured on a website from Johns Hopkins Oncology Center’s liver tumor center.  The video offers a look into the life of a patient living with cancer, the effects of the diagnosis and treatment on her family, and the impact of advances in cancer treatment that truly made a difference in her life and the lives of her family and friends.


The last survivor news story is not a personal one, but something that many people across the country have seen for themselves this past week: the return of Steve Jobs to the public stage in his role as CEO of Apple after a liver transplant to treat cancer that had spread to his liver.


Mr. Jobs has been very quiet about his disease, but he clearly is a remarkable survivor.  It’s fair to say that there have been questions raised about his treatment, but there is little question that he has returned to a very active role at his company, and a very active role in life.


Celebrities—as I have written and said before—are special people.  They have accomplished much, but they are still people.  On the public stage, they represent not just themselves, but the millions of others out there with cancer who function every day trying to earn a living, deal with treatment, and live their lives. 


Mr. Jobs has accomplished much, but perhaps one of his greatest accomplishments right now is representing the cancer survivors who live among us every day, doing what they need to do to live their lives.


We are surrounded by people who have survived cancer, who are being treated for cancer, who are struggling with cancer.  Cancer is part of their lives, and it is part of our lives. 


But we have far to go.  We still don’t have enough survivors.  We still have those who struggle with the long term impact of a diagnosis of cancer.  We still have much to learn about the side effects of cancer treatment.


As cancer survivors—in particular those diagnosed earlier in life--“age out” of their disease, their doctors become more concerned about their other medical problems, such as blood pressure and elevated cholesterol.  They may not know what has to be done to monitor the long term effects of cancer.  They may not even be able to find the information about the original diagnosis and treatment.


We don’t do a good job of disseminating the information about the long term effects of cancer treatment, and we don’t empower patients to have access to the information.  There is much we don’t know about the long term effects of treatment, and we don’t do enough research to answer the questions about the potential downsides of our successes.


This message is one of hope.  It is also a call to action, about how we need to learn to provide cancer survivors, their families and their physicians accurate information about  the long term effects of cancer care.  We need to provide the funding for research to find out what we don’t know about the impact of being a cancer survivor, both physically and psychologically.

We can accomplish miracles today that 30 years ago were a gleam in our eyes.  But those miracles come with a cost.  Given the alternatives, I hope you would agree that these are costs we gladly choose to bear. 


At the same time, we can’t ignore that these long term effects exist. It is our responsibility to do more to close the gaps about what we know and what we don’t know, and how we help survivors continue to survive their journey--even as they go on with the rest of their lives free of what once was a fatal disease.

Filed Under:

Cancer Care | Treatment

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.