Monthly Archives: October 2013

Scuba and screening

Every day, we each make choices. Some choices are pretty obvious and require little discussion or thought; for others, individual preference plays a major role with different people making different choices based on different perspectives.

A personal example involves a trip my wife and I plan to take to a warm, seaside location in January. One choice is whether we will use sunscreen. This is a “no-brainer.” Another choice is whether we should go scuba diving.  I love scuba diving and jump at every chance I get to spend time swimming with the colorful fish of the underwater world. My wife makes a very different calculation. Factors that impact on her decision include being in cold water, breathing through a small rubber tube, and the thought of being in the water with potentially nasty creatures.  When it comes to sunscreen – the choice is obvious. When it comes to scuba diving, we each made our own calculation based on our own perspective. Continue reading

To boldly go …

OK, I admit it.  When I was a kid I was into Star Trek (even had a picture of the starship Enterprise on my wall).  Not the Star Trek movies or the newfangled “Next Generation” or “Deep Space 9” series, but the original series first broadcast in the 1960s.   I was fascinated by the transporters, flip-top communicators, and medical “tricorder” that was waved over the patient by Doctor McCoy (called “Bones” by the future Iowan Captain Kirk) to make a medical diagnosis in seconds.

Fast forward 45 years …  I am still waiting on the transporters, but Star Trek’s flip-top communicators seem quaint compared to today’s smart phones.     How about the medical tricorder?  We have CT, MRI and PET scanners that were not on the starship Enterprise radar screen 45 years ago.  This week, at the University of Iowa, we rolled out another type of medical test that goes even further into the “final frontier” of molecular medicine. Continue reading

From mud to golden fields

Earlier this year, I drove from Iowa City to Des Moines for the spring meeting of the Iowa Cancer Consortium (ICC) – Iowa’s collaborative cancer control program that focuses on reducing the burden of cancer for all Iowans.  It was a time when we were experiencing heavy rain and flooding.  The sky was gray, and the fields were bland and full of pockets of standing water.  There was talk that, with all the mud, the crops might never get planted.  Fortunately, Iowa farmers eventually got the seeds in the ground.

Last week I attended the fall meeting of the ICC.  The early morning drive to Des Moines was spectacularly different with the glow of the rising sun shining on the golden crops and rolling fields.  The harvest was going full bore, with farmers up early and in the fields.  I listened to Iowa Public Radio on the drive, and heard the crop reports indicating that, despite the wet spring, the yield this year will be better than expected.   The farmers knew that if they were patient and persistent, they would reap what they sowed. Continue reading

More is not always better

My father was diagnosed with a widespread Adenocarcinoma of Unknown Primary several years ago when he was in his mid-80s. A short course of chemotherapy had a modest impact on the cancer, but the side effects of the therapy were significant, and he decided not to continue the chemo. He enrolled in hospice, and other than a few short stays in the hospital, spent the remaining months of his life at home doing what he loved, surrounded by family. We had many discussions during that time about what therapies he should take, and what therapies he should not to take. I still miss him dearly, but am comforted to know I did what I could to assure he had the highest possible quality of life during his final months.

My advice to my father, and to my patients, is based on the knowledge that for some patients, intensive therapy with curative intent is appropriate. For others where cure is not possible, gentler therapy geared toward maintaining or improving quality of life can sometimes be a better choice.

Assuring every patient across the country gets the best possible cancer care is difficult. There is a growing demand for cancer care, treatments are increasingly complex, there are not enough well trained clinicians in the workforce, and costs of cancer care continue to rise. In addition, our current use of cancer care resources is out of balance. Some patients receive therapy that is unlikely to help, yet is costly with respect to both quality of life and actual dollars. Others do not have access to quality cancer care.

The solution requires a fundamental change in our approach to cancer care. The Institute of Medicine (IOM) recently outlined the challenges in our cancer care delivery system, and how we might respond to them, in a report titled “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.”

The new course outlined in this report will not be easy but is desperately needed. Academic cancer centers such as Holden Comprehensive Cancer Center must take the lead in charting this new course in each area of our tripartite mission of education, research and patient care.

Education
We need to improve our teaching of communication skills to the next generation of cancer clinicians so those clinicians can help patients and their families clearly understand the goals of a particular cancer therapy and what they can expect to gain (or lose) from that therapy. The decision not to use every possible cancer therapy for every patient should not be equated with giving up, rationing, or responding to “death panels.” Instead, choices should be based on what is right for each patient. With better communication and more accurate expectations, more patients would choose to do what my father did, and decide to focus on quality of life.
Research
In addition to basic and clinical cancer research, we need to explore how therapy impacts on quality of life and conduct health services research exploring more effective and efficient approaches to delivering quality cancer care to the underserved.
Patient care
In addition to providing state-of-the-art, evidence-based anti-cancer therapy, we need to provide care focused on enhancing the quality of life.

During the last few months of his life, my father repeated one of his favorite maxims—“there always will be ten leading causes of death.” I would like nothing more than to see cancer come off that top ten list, but striving for that day should not blind us to the fact that the goal of medical education, research, and care is not only to extend the lives of our patients but also to improve and enhance their quality of life. To achieve that goal, more is not always better.

Difficult news

I am not sure how to begin this blog so I will just come out and say it.  Last week I shared with you Maddie’s inspirational story – she is an 8-year-old girl who has been struggling with leukemia more than half her life. Her parents had sought out a highly experimental immunotherapy. When I met her just a few weeks ago, it was clear the therapy was having a powerful effect on the leukemia and she was back to being a vibrant 8-year-old girl.

This week, I learned the sad news that Maddie’s leukemia has returned, and that she and her family are considering next steps.  The cancer researcher in me is not surprised and sees this as further evidence we must proceed with research at all deliberate speed; my human side is devastated.  Our thoughts and prayers go out to Maddie and her family at this difficult time.

Ironically, I learned this news on the same day that our federal government shut down.  Indeed, the email telling me of Maddie’s relapse was sandwiched between two emails from colleagues at the National Cancer Institute (NCI) announcing they were being placed on furlough due to the shutdown.  What does this mean? In addition to all of the issues you heard about in the news, it means the suspension of new NCI clinical cancer trials and review of new grant proposals. NCI employees are now legally forbidden from contacting cancer researcher collaborators across the country. There is no question in my mind that the progress of cancer research will be slowed.

Last week, I described how Maddie had matured beyond her years.  She has a remarkable understanding of how her personal story impacts the bigger picture, yet still enjoys being a young girl.  Sadly, she once again has to put those childhood pursuits aside to deal with an incredibly difficult challenge.  Meanwhile, our congressional leaders continue to act like poorly-behaved children and focus on themselves, and not on the very real needs of those they serve.

There is an awful symmetry here, and it leads one to think about what would happen with respect to setting priorities if roles were reversed.  If our congressional leaders were in Maddie’s shoes (or those of her parents), would that change their approach?   I think it would.   And how about the other way around?  I am not one to quote Bible verses, but Isaiah 11:6 seems particularly poignant to me at this point in time: “and a little child shall lead them.”

If only it were so…