Friday, April 22, 2011

RIP Grete Waitz

How could I have missed this? My total hero during the 80's was a willow-wisp of a woman with a blonde ponytail, Grete Waitz. A Norwegian, tough as hell, and nine time winner of the New York City Marathon when women were just discovered to be strong enough for the distance. (Yes, check my yearbook. My goals were to run the NYC marathon and write the great American novel. Geesh.) I had pictures of Grete cut out from Runner's World pasted into my school notebooks. She was a sensation, a discovery for me of how strong and successful a woman could be, of what the body could do. She broke the 2 1/2 hour barrier for the marathon and kept going -- to the olympics and endless titles. She placed second to my other hero, Joan Benoit, in the first ever women's marathon in Los Angels. Waitz died on the 19th in Oslo of cancer.

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Saturday, December 11, 2010

Discussing the Atlas Study

Thaddeus Pope has posted the entire presentation from yesterday's panel at the New America Foundation at his site. Joanne Lynn, David Goodman and others discuss the Atlas Study which shows that those living in different regions around the country receive varying levels of end of life care. You can watch it here.

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Thursday, June 10, 2010

Doggerel Fails Me.

Unhelpful verse in the cancer ward meditation room. A guest post by Mary Valle, cross-posted from Killing the Buddha.

I’m participating in a clinical trial for a new breast cancer vaccine. You can read in the Baltimore Sun about the last round, which treated terminal cancer patients, or watch a video of my doctor, Leisha Emens, talking about it here. My group is comprised of Stage III patients; in my case, I had a very aggressive kind of cancer which spread beyond my breast. I have been treated for it; I am currently in “remission.” That is, I “show no signs of disease.” But no one really knows if cancer cells are in my body, and that’s how it returns. And there are a lot of recidivists. So I, understandably, have high personal hopes for this vaccine.

A friend was asking me if we cancer patients talk while in the clinic, and I explained to her that the people in my study, some of whom fly in once or twice or even six times a week to participate, all attend at different times. There are also people who are participating in other studies. Then, there are all the “regular” cancer patients. I have never been in a cancer ward that is not insanely busy, and people don’t really chat with each other all that much. People tend to keep their eyes to themselves. It’s just too much suffering to take in at once. If you start looking around, you see deformities; you see families; you see the sadness on people’s faces. We’re all expected to be brave in front of the civilians, but in the waiting room or the phlebotomy room, or the chemo area, the masks seem to fall.

However, I did meet another patient recently whose story made me so sad I was motivated to breach the generically-named Meditation Room and hork up a prayer for her. I’ve kind of been saving the Meditation Room as a special treat. Yes, that’s right. I take my joys where I can find them. Wondering what I was going to find inside the modernish, oceanic stained-glass doors has entertained me quite a bit. What could it be? Would it be like the great chamber of the Wizard of Oz? Would there be a little waterfall? Some kind of aural mood-lighting, like whale songs or ocean waves? An altar, and if so, what would be on it? Or would it literally be a meditation room: I fantasized about opening the doors to a perfect Zen enclosure, all spic and span and sparse and somehow freshly-aired. There, waiting, would be a firm zabuton just waiting for me to perch upon it, close my eyes and surrender myself. My imagination gets me through a lot.

I looked sideways as I pulled open the heavy glass door, but no one even noticed I was going in. Did I want someone to wink or give me a thumbs-up or “Hork one up for me, Mary!” Probably. It’s always nice to be observed in acts of piety. The space was windowless, as predicted, and far smaller than I imagined. In one corner was a little bookshelf with major religious texts on it. There were some nature tapestries, hanging fake plants, a plaque dedicating the space on behalf of the parents of a dead patient. There was a Bible propped open to the book of Esther on a low table in the “altar” area. Then, on a table above it, where I imagine the tabernacle might be, was a plaque with the “What Cancer Cannot Do” poem. In calligraphy.

For those unfamiliar with it, this is a piece of doggerel you come upon not infrequently in the cancer business. Look, I don’t care if people want to wear pink ribbons and festoon their cars with cancer stuff and drink out of “Cancer Cannot” coffee mugs. Not my thing, but if it comforts others, that’s great. I am well aware that my sensitivity to the built environment sometimes makes me feel a little left out, but what can I say? I won’t go to an ugly church.

I grimaced and sighed. Because this “poem,” besides being badly written, just isn’t true. It comes in a lot of versions, both secular and “inspirational.” It goes something like this:

What Cancer Cannot Do

Cancer is so limited…
It cannot cripple love.
It cannot shatter hope.
It cannot corrode faith.
It cannot eat away peace.
It cannot destroy confidence.
It cannot kill friendship.
It cannot shut out memories.
It cannot silence courage.
It cannot invade the soul.
It cannot reduce eternal life.
It cannot quench the Spirit.
It cannot lessen the power of the resurrection.

Cancer can do all of this stuff. (The last three, I’m not sure about.) I wonder if other people have had the same reaction to something which is supposed to be comforting, but to me, seems a bit accusatory since all of these things (except for the last three) have actually happened to me. Cancer, it turns out, can do a lot. This is just tomfoolery; why would you mess with people who may be dying like that? Why possibly make them feel bad if their hope has been shattered, their peace has been eaten away, their soul has been invaded, etc.? And here’s a crappy poem telling you you’re wrong?

But I backed down from the ledge: people must like “Cancer Cannot” or you wouldn’t see it so much. It was time to do what I had come for. I took a seat and said a prayer for my new friend, and for the parents who donated the Meditation Room and their daughter, and decided that I’d contribute my own book to the Meditation Room collection, seeing as how there was no poetry on the shelf. The Collected Poems of Emily Dickinson: not a lie in the bunch.

Mary Valle lives in Baltimore and, in the latest Killing the Buddha book, Believer, Beware, wrote about her adventures in sex ed at Catholic school. She blogs on Killing the Buddha as The Communicant. For more Mary, check out her blog or follow her on Twitter. She is currently working on a novel called The Hexagon, which is, roughly, Rosemary's Baby set in a Waldorf-type school.

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Saturday, March 20, 2010

The ER and Cancer Patients.

Suzana Markowski has a new post at Pallimed about emergency room use and cancer. Her post looks at a new study of ER visits and examines ways to better treat end of life issues. Here's a clip:

We know already that most people want to be at home with family at the end-of-life, we also know that most end up in hospital or institution. We have hypothesized that increasing access and enrollment to hospices might help people meet this goal. This article seeks to understand how frequently and why patients with end-stage cancer choose to go to the ER.

So this begs the question… what percentage of patients with cancer visit the emergency room during the last 6 months and 2 weeks of life?
Of the 91,561 patients who died of cancer between 2002 and 2005, 84% of patients visited the ER in the 6 months prior to death and 34% of patients visited in the last two weeks before death. They outline the principle reasons for emergency room visits: primary cancer (mostly lung cancer), uncontrolled symptoms (pain, dyspnea and other non-pain symptoms), caregiver fatigue, and infection.
Top reasons for ER visits among patients with cancer:

While many of the patients studied ended up admitted to hospital, the authors – and I believe, rightly so – postulate that most may have avoided acute-level care had the quality and quantity of care had adequately supported the needs of both patient and caregiver. Instead of emergency room care, most of these patients required “either additional support to remain at home or direct transfer to a palliative care unit or residential hospice.”

Barbera and colleagues suggest that “comprehensive and coordinated” palliative care could serve the needs of most of these patients and their caregivers and meet this demand for quality and quantity of care, allowing patients to have symptoms tended to at home, in clinics, or in in-patient or residential hospice facilities.

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Thursday, January 7, 2010

Pseudoscience: Opioids, Contraception, Abortion and Cancer.

It's a great day for ideologically motivated pseudoscience!

From BeliefNet, a new study that, against all odds, establishes a link between contraception, abortion and cancer.

And from the super GeriPal, a debunking look at the swelling but false meme that opioids like morphine cause cancer growth.


Why is it important to not leap to the conclusion that opioids cause cancer growth? Two recent examples come to mind: hormone replacement therapy for post-menopausal women and vitamin E. Early retrospective studies (in humans, not mice) seemed to demonstrate that hormone replacement therapy led to reduced mortality. Unfortunately, large prospective cohort studies showed the opposite to be true! When researchers went back to re-examine the earlier studies, they found those earlier studies failed to account for important baseline differences in women: those who were healthier were more likely to take hormone replacement therapy, and therefore had better health outcomes that were attributed to the drug. Similarly, there was a great deal of excitement about vitamin E, including bizillions of laboratory studies that showed plausible mechanisms by which vitamin E could reduce heart attacks (antioxidant properties, etc). Again, large studies showed the opposite: people who do not take vitamin E live longer and have fewer heart attacks than people who do take vitamin E. In both the case of hormone replacement therapy and vitamin E, patients were taking the drug and health care providers were recommending treatment based on early evidence. And people died.

snip

As Christian Sinclair (of Pallimed) noticed, if you Google search "morphine cancer" the fourth hit is "Pain drug morphine may accelerate cancer growth | Reuters." Think of all of our patients and caregivers who, seeking information, are clicking on that link.
Let's set the record straight.

The world is full of suppositions and pseudoscience that is meant to support an ideology - the media plays sucker again and again. Got your own examples? Post them in comments!

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Tuesday, November 24, 2009

Debunked: Morphine Causes Cancer.

Thanks to the exceptional folks at GeriPal for debunking the latest meme that morphine stimulates cancer growth:

Over the last week Reuters, ABC news, MSNBC, BBC News, and more than 75 other outlets reported on how two "two new studies add to growing evidence that morphine and other opiate-based painkillers may promote the growth and spread of cancer cells." What was most shocking were the headlines used to promote the stories:
All these articles (most stemming from an initial Reuters report) discussed the recent presentation by a group from the University of Chicago on the mu-opioid antagonist methylnaltrexone (otherwise known as Relistor or “that new opioid induced constipation medication”). This work, as presented at a meeting in Boston, revealed that use methylnaltrexone prevented tumor-cell proliferation and migration in cultured lung cancer cells. The group also presented work revealing that genetically altered rodents lacking the mu-opiate receptor failed to develop tumors after being injected with Lewis lung carcinoma cells, something that did occur in normal mice. This is an interesting line of research and one that gave the makers of Relistor a shot in the arm (as one website put it – “a possible new indication for Progenix's Relistor could revive its fortunes”.) I find the pathophysiology behind this incredibly interesting from an academic standpoint, however it is neither something that would warrant such dramatic headlines nor spur thoughts that it is anything but research in its infancy.

What about the claim that there is “mounting clinical evidence” that morphine may accelerate cancer growth? The only real clinical studies in this regard come from a single institution in Ireland and are basically a couple retrospective cohort studies comparing regional versus
general anesthesia. The first one of these articles (Anesthesiology. 2006; 105(4):660-4) showed a beneficial relation between paravertebral block and cancer recurrence in women undergoing breast cancer surgery. The study’s authors acknowledge that “selection bias and the effects of unmeasuredconfounding variables” could not be excluded, as well as the fact that “relevant information such as the amount of morphine given” was not available in the records. The second study was nearly identical except it was in patients undergoing radical prostate surgery (Anesthesiology. 2008;109(2):180-7)

The most important take home point is that none of these studies actually looked at opioid use (although many of the news articles vaguely cite these studies as evidence for morphine’s deleterious effects on cancer). Even if you want to argue that these were high quality studies and there is a clear benefit of regional anesthesia, opioids should not be singled out as the cause. Benefit of regional anesthesia may be due to a myriad of other effects of regional anesthesia including the lack of volatile anesthetic agents or an improved stress response. These studies are noteworthy, but I agree with the authors of these articles that they should “be viewed as generating a hypothesis and an estimated
effect size for future large randomized controlled trials”.

So if you have a patient on morphine asking you whether “morphine will make my cancer worse”, the answer is no. There is no clinical evidence that morphine, or any other opioids, cause real harm through stimulating cancer growth. There is though significant high quality evidence for their benefit in relieving
pain and suffering.

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