-Henry VIII, Act III, Scene ii

It is time for The Cheerful Oncologist to sign out. I have decided to take a holiday from writing and therefore am cutting the cord from ScienceBlogs. I send thanks to those readers who put up with my malarkey over the past three years. If the fair maiden Blogorrhea, the muse of web logging, returns to bewitch me at some point I may start again, but until then I place my pen down and say to all, “God Bless.”

Be wise in the way you act toward outsiders; make the most of every opportunity. Let your conversation be always full of grace, seasoned with salt, so that you may know how to answer everyone.

-Colossians 4:5-6

Die is a short, simple word. The problem is that I rarely use it when I speak to my dying patients, and I don’t think I’m alone.

According to Dr. Berry, one of the reasons why we eschew the “D” word when talking to patients about their prognosis is to avoid upsetting them with the use of such blunt terms since they are already in distress as it is. Another explanation is that we doctors find it awkward or unpleasant to bring up such bad news, which the author believes is a reflection on the perverted way our society identifies death as a distasteful subject, one that is almost taboo and should be identified with euphemisms. He remarks on other possible explanations:

It is not hard to see why physicians might have trouble talking about death and using the word death; we live in a culture where many physicians and patients may see death as an admission of failure or of giving up.

For the patients we have known for many years and with whom we have developed deep bonds, we may not want to use the word “death” because we are starting to feel our own sense of loss and the beginning our own grieving.

I understand where Dr. Berry is coming from with his request to speak more clearly about dying when counseling the dying, but I have a twist on his advice. First, here is his approach:

It’s time to take the next step in opening up the discussions we have with our dying patients. The next time you must let someone know they are dying, the best way of doing this may be to say, “You are dying.” It’s more than just semantics. Using the word “die” will clarify our conversations with patients and let them know that death doesn’t need to be considered unnatural or a failure.

Telling every patient “You are dying” seems too formulated to me. It pays no respect to the tremendous amount of hard work the patient has put into the mind, into developing and maintaining a hopeful and courageous attitude during his or her illness, an outlook that reduces anguish and perhaps even steels the body to fight on longer than it was meant to. I have seen the power of the mind and heart, and what it can do to support a body infested with cancer, and the results are impressive. I therefore respect the unique spirit that resides within each of us, and when I see this power still shining in a failing host who wants the truth I might just say this:

“Your body is dying, but not your spirit. The fire that blazes within you, that has allowed you to carry on so long with this disease, is still bright. It will not vanish until your body reaches its final breath, and on that day, on the day of your death, the person that inhabited your body will indeed disappear, yet it will live on – in the memories of those who knew and loved you. Such is the power of the human spirit.”

Point number one: “Work-related stress can kill, study finds”

Point number one again: “The team conducted seven surveys over a 12-year period and found chronically stressed workers — people determined to be under severe pressure in the first two of the surveys — had a 68 percent higher risk of developing heart disease.”

Point number one a third time: “Stressed workers eat unhealthy food, smoke, drink and skip exercise — all behaviors linked to heart disease…stressed workers also had lowered heart rate variability — a sign of a poorly-functioning weak heart — and higher-than-normal levels of cortisol, a “stress” hormone that provides a burst of energy for a fight-or-flight response. Too much cortisol circulating in the blood stream can damage blood vessels and the heart.”

If you are stressed out at work, please keep in mind the fact that you may be increasing your chances of a heart attack. How you reduce the effects of stress on your body is up to you, but if you’re so inclined, try this piece of advice from Peter Kokkinos, director of the Exercise Testing and Research Lab at the Veterans Affairs Medical Center in Washington:

Older men who were classified as “highly fit” died at half the rate of those who were not fit in a major long-term study, U.S. researchers said on Tuesday. The study of more than 15,000 U.S. military veterans is one of the largest yet to show that exercise extends lives regardless of race or income.

I can’t emphasize enough the salutary effects of regular exercise. Now get out there and boogie!

The treatment is called High-Intensity Focused Ultrasound, or HIFU. The title of the story is:

“Despite Doubts, Cancer Therapy Draws Patients”

Doubts? Who’s doubting the treatment – the doctors who perform it? The company who makes the product? The patients themselves? Of course – it is physicians in America who don’t have access to the treatment who are skeptical. Such attitudes are not necessarily detrimental to the advancement of prostate cancer care; most oncologists prefer to see at least a modicum of sound clinical evidence for a new treatment before recommending it. In the matter of HIFU, however, I believe that some caveats need to be given to both sides before anyone jumps to conclusions about it being the latest example of quackery.

HIFU for prostate cancer involves sedating the patient and then using a transrectal ultrasound to destroy prostate cancer cells with temperatures in excess of 80 degrees centigrade. The controversies surrounding this procedure have been clearly listed by experts in prostate care. Here are some of them:

1. It is expensive and not covered by health insurance.
2. Patients must travel out of the country to receive it.
3. HIFU has been reported to cause the very symptoms that many patients are trying to avoid with this therapy, viz. erectile dysfunction and urinary incontinence.
4. American trials have not yet been completed, so no conclusions about the short term benefit of HIFU in American men can be made.
5. Results are not guaranteed; seven published trials show local control rates of around 70-85% – not 100%.
6. No long-term follow-up (that is, 10-20 years) has yet been published. Does the cure rate plateau with HIFU or do patients continue to relapse as the years go by?

With these doubts, why do I personally believe there are reasons for hope with HIFU? A literature search returned 259 medical articles describing HIFU for prostate cancer alone, and some of the data suggest that the treatment, with further refinement and research, may turn out to be effective.

From Japan (181 patients): The biochemical disease-free survival rates at 1, 3 and 5 years in all patients were 84%, 80% and 78%, respectively…High-intensity focused ultrasound therapy appears to be a safe and efficacious minimally invasive therapy for patients with localized prostate cancer, especially those with a pretreatment PSA level less than 20 ng/mL.”

From Germany (402 patients): The negative biopsy rate [called "HIFU failure"]observed in the T1-2 primary-care population was 87.2%…These short-term results obtained on a large cohort confirm that HIFU is an option to be considered for the primary treatment of localized prostate cancer.”

from France (227 patients): “The actuarial 5-year disease-free survival rate (DFSR), combining pathologic and biochemical outcomes, was 66%. DFSR showed a significant decrease when stratified according to initial PSA level: 90% with PSA

It may turn out that HIFU for good prognosis prostate cancer is no safer nor any better than surgical resection or radiation therapy, which are the gold standards of treatment in the U.S. The New York Times article implies that men are being ripped off by unscrupulous doctors who are charging exorbitant fees for the procedure. I think the reporter is exaggerating the controversy for effect, which as all intelligent readers know is a trick that the newspaper performs effortlessly. My feelings on new technological treatments such as HIFU can be summed up by this statement from a January 2008 review in the American Journal of Roentgenology:

“Although a great deal about HIFU physics is understood, its clinical applications are currently limited, and multiple trials are underway worldwide to determine its efficacy.”

Excellent. As Nero said, “Let the trials begin.”

We all enjoy wielding certain favorite words in our conversation or in writing, and as a fierce proponent of increasing one’s vocabulary I’d like to share some of mine. (Disclaimer: I don’t use them as often as I should, but that’s only because I’m shy).

adduce: to bring forward in argument or as evidence; cite as pertinent or conclusive. “Papa interrupted John before he could adduce any more reasons why he should be allowed to stay out late.”

omphaloskepsis: literally, the contemplation of one’s navel, which is an idiom usually meaning complacent self-absorption. “After an hour of listening to her tedious exercise in omphaloskepsis I quietly signaled our waiter for the check.”

unctuous: characterized by excessive piousness or moralistic fervor, esp. in an affected manner; excessively smooth, suave, or smug. “The senior oncologist on the panel annoyed us all with his unctuous presentation of the case history.”

lickspittle: a contemptible, fawning person; a servile flatterer or toady . “The Führer slammed his fist into the map, sending lickspittles hovering nearby into a frenzy of apologies.”

hebdomadal: taking place, coming together, or published once every seven days; weekly:. “Mark rang off, grabbed his briefcase and headed for the elevator, anticipating a hebdomadal date with a dry martini.”

See how much fun it is to use colorful words? I’ll add some more later if I can find the time in between my uxorious propensities.

ARE YOU EXPERIENCING ANY OF THESE SYMPTOMS?

*chest pain, pressure, discomfort, tightness or squeezing, with or without nausea / sweating
*inability to breathe
*loss of consciousness
*worst headache of your life including at least the past six incarnations
*uncontrollable vomiting, or vomiting up blood
*hemorrhage from the rectum, with or without light-headedness
*traumatic injury
*abdominal pain that is severe enough to interfere with your ability to remain upright, not to mention remain calm, cool and collected
*sudden loss of sensation or muscle strength
*altered mental status

IF YOU ANSWERED YES, PLEASE GO TO THE NEAREST EMERGENCY ROOM.
IF YOUR SYMPTOMS ARE NOT SEVERE NOR MENTIONED ABOVE, PLEASE CALL YOUR PERSONAL PHYSICIAN AND LEAVE US THE HELL ALONE – WE’RE SWAMPED!

Patients seeking urgent care in U.S. emergency rooms are waiting longer than in the 1990s, especially people with heart attacks, U.S. researchers reported on Tuesday.

According to the experts, more and more hospitals are closing their E.R.s because, as study author Dr. Andrew Wilper states, “…in our current payment system, emergency patients are money-losers for hospitals.”

In other words, the fact that hospitals do not get adequately reimbursed to run an emergency room, combined with the hypothesis that increasing number of patients are using the E.R. as their family doctor, combined with the fact that emergency rooms need to be redesigned to allow for better access, treatment, transportation and coordination of care (plus given a larger space) means longer waits to see the E.R. doctor.

I can attest from personal experience that the emergency room is a lousy place to spend an evening. Are there any solutions? Dr. Wilper et. al. in the paper from Health Affairs have some ideas:

Reversing the trend of longer ED waits would likely require multiple reforms. Possible interventions include expanding insurance coverage and access to primary care resources to increase alternatives to ED visits; directing hospital resources to medical need (for example, the expansion of ED resources) instead of profitable but unnecessary services; increasing available ED space, staff, and specialty consultation services; and modified management of elective surgery scheduling.

Nice thoughts, but “directing hospital resources to medical need instead of profitable but unnecessary services”? Come on – cut the crap! The only way to ensure that emergency care will improve in this country is to increase reimbursement to the point that hospitals can afford to expand their E.R. care, or force hospitals to provide care (if I may paraphrase Ayn Rand) at the point of a gun, known to some as the term socialism.

Memo to all idealists: just because some Oxford don pronounces a certain medical treatment as “unnecessary” doesn’t mean that the American people will gladly stop having said treatment “for the common good.” Good luck convincing us that a single-payer government run universal health care system will bring peace, love and understanding to all those who cry out in the wilderness for relief from their suffering. Remember, suffering doesn’t go away magically with the wave of a pen from Congress, or the opening of the vaults of Fort Knox. Someone has to treat the sufferer, and that someone is people like me. Unless Uncle Sam decides its time for mandatory medical service, the little people like me can and will vote with our feet, thus the continuing crisis.

My patient lay in her hospital bed, head at the proper thirty degrees of comfort, staring at some private point on the wall across the room. Her anemia had worsened and I couldn’t tell if it was from the effects of cancer or of chemotherapy. It didn’t really matter since the treatment was the same: two half-liter units of merlot-colored blood, courtesy of a pair of anonymous angels of mercy, also known as donors.

“I really don’t want to do that.”

“You don’t have to, but getting two bags of blood will help your fatigue and tiredness.”

“Yes, but how do I know I’ve got good blood?”

“How do you know you’ve got good blood? You mean is the blood safe?”

Her eyes met mine. “I mean, have I got the right kind of blood for this?”

I recalled what she had shared with me during our first visit, about how she had spent forty years working with school children while raising her daughters. She possessed an aura that reminded me of walking through summer meadows, but until today its source was unclear. As she fussed with her blanket I suddenly seemed to see behind her hardened voice. Here was a woman who had spent her life giving to others, who never showed up late nor petulant, a wife and a mother, an independent soul who now was forced to ask for mercy from a disease that harvested the living like a scythe. I still wasn’t sure what she meant but answered her with a smile.

“You’ve got great blood – you worked your whole life to earn it. You know, you’re my role model on how to live courageously. I can see the strength flowing through those veins.

“You’ve got the right kind of blood all right, and I’ll remember that whenever I think that mine is faltering.”

“Waistline grows along with economy“

“Wealth and Waistlines – A new book explains how the obesity epidemic has been shaped by economics, and what we can do to reverse the trend“

The Fattening of America, by Eric A. Finkelstein and Laurie Zuckerman, is a fascinating new book proffering an economic explanation as to why more and more Americans are obese – I think. I haven’t read it but that didn’t stop me from perusing the news stories coming out on Dr. Finkelstein’s analysis of obesity and its relationship to our modern economy.

If I may sum up his theses on why we’re getting fatter:

1. The evolution of our diet, as manifested by what foodstuffs make a nice profit for those involved in its creation, has made it more costly to buy healthy foods than mass-produced fattening junk food that is flavored with ingredients from the corn and soybeans farmers are getting dough to grow.

2. The evolution of our economy, as manifested by what our employers are looking for, has forced gazillions of Americans to work in sedentary jobs in search of better wages than can be found in active jobs (think lawn maintenance) that don’t pay as well.

3. The evolution of modern health care, as manifested by our ability to keep obesity-induced diseases from prematurely bumping off citizens before their time, serves to reinforce the attitude that obesity isn’t really all that bad for us because our talented doctor will certainly keep us going with new, exciting pills from Big Pharma.

4. It’s just too damn hard to find the time to cook smart meals, avoid fast food and exercise – unless, of course, you pay us to lose a few pounds. Grease our palms (or put us on network television) and we just might interpret this as the afflatus to deflate us.

5. Leisure time activities centered around sitting on our behinds provide us with much more comfort and joy than things such as say, bullfighting, mountain biking or anything else that denies us the divertissement housed within the latest iPod-DVD-Internet-PS3-Gameboy device.

As Dr. Finkelstein summarizes: “A lot of people just aren’t interested in carving out the time it would take to be physically active. Plus, it’s cheap and convenient to consume lots of great-tasting food. I argue that obesity is a side effect of any advanced economy. When you mechanize a society to the degree that no one has to do anything, no one’s going to do anything. Combine that with cheap, prevalent food, and the result is bound to be weight gain.”

I never thought of obesity as anything but a public health disaster, but perhaps I am being too harsh. As long as our economy can afford to pay for the medical care of obesity-related illnesses, maybe we should let folks expand their waistlines and not criticize them.

Of course, there is another way to slim down the population. As sinophiles know, Chairman Mao proved to be a genius at getting people to eat less – the only problem is that this was an unexpected consequence of a ‘separate plan’ – leading to the starvation of over 20 million of his own people. Oops.

Until folks realize that the best way to maintain a healthy weight is to not eat so doggone much and (as annoying as it is) reserve some time each day to do something physical, they have no chance to avoid plumping up – unless our government decides its time for the Amercian version of The Great Leap Forward.

Anyway, I am grateful for the chance to inform and entertain my readers – all four of you (just kidding). I hope to continue on as long as it can be determined that I have something worthwhile to say, which according to the International Web Log Rating Guide is a characteristic found in 0.000000000000001 % of all extant blogs.

Just kidding. Or am I?

By identifying how seldom oncologists provide empathic support to patients, the study illuminates the potential benefit of teaching such skills to doctors. Previous research has shown that patients who receive empathic responses (called “continuer statements,” as opposed to “terminator statements”) experience less anxiety. In one study cancer survivors who watched videotapes of physician-patient encounters, with and without just 40 seconds of compassion expressed by the physician, rated the empathic doctors as “warmer and more caring, sensitive, and compassionate.” The study participants also reported less anxiety after watching the “enhanced compassion” tape. Listen to the introduction to the Duke study, published in the Journal of Clinical Oncology:

Cancer care involves addressing patient emotion. When patients express negative emotions, empathic opportunities emerge. When oncologists respond with a continuer statement, which is one that offers empathy and allows patients to continue expressing emotions, rather than with a terminator statement, which is one that discourages disclosure, patients have less anxiety and depression and report greater satisfaction and adherence to therapy.

The senior author of the study, Dr. James A. Tulsky, director of the Center for Palliative Care at Duke University Medical Center, summarizes the problem in a New York Times article about the project:

“It is absolutely the role of the oncologist to provide a bit of emotional support.”

“One doctor who was especially good with patients, and who often consulted on very serious cases, opened discussions with new patients by saying, ‘Tell me what you understand about your illness,’” Dr. Tulsky said. By contrast, with other doctors, Dr. Tulsky said, “There were a number of times when patients brought up emotional content and it went right by the doctors.”

“For instance, a patient would say, ‘I’m scared,’ and the doctor would go off on a ‘scientific riff’ about the disease. We saw that a lot. The doctors don’t lack empathy,” he said. “They just have trouble expressing it.”

As suggested in the article, patients should not feel ashamed to express feelings of distress, which can often be assuaged with a few words of kindness and encouragement. Sometimes oncologists need to be reminded that the body sitting before them is not a tumor host but a living being, filled with the same emotions that abound in all living beings, including doctors who one day will certainly find themselves sitting in a similar chair that their patients fill at this moment.