The Cheerful Oncologist

Goodbye to ScienceBlogs

Fri, 25 Jan 2008 09:08:00 -0600

Farewell! a long farewell, to all my greatness!
This is the state of man: to-day he puts forth
The tender leaves of hopes; to-morrow blossoms,
And bears his blushing honours thick upon him;
The third day comes a frost, a killing frost,
And, when he thinks, good easy man, full surely
His greatness is a-ripening, nips his root,
And then he falls, as I do.

-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

"You Are Dying - and I Hate Myself for Saying It"

Thu, 24 Jan 2008 12:59:54 -0600

Dr. Scott Berry, a medical oncologist at the University of Toronto, has written an interesting essay in this month's Journal of Clinical Oncology entitled "Just Say Die." His point is that doctors are hesitant to use the words "die" or "death" when counselling patients who are in the process of doing exactly that - dying:

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."

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Exorcising Stress From Your Life

Tue, 22 Jan 2008 20:56:07 -0600

If you have an important point to make, don't try to be subtle or clever. Use a pile driver. Hit the point once. Then come back and hit it again. Then hit it a third time-a tremendous whack.
-Winston Churchill

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!

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Frying Prostates in Puerto Vallarta

Mon, 21 Jan 2008 13:39:51 -0600

The New York Times has a story published last Friday about American men traveling to Mexico to receive a treatment for prostate cancer that is not approved in the United States. The article implies that this treatment is an unproven entity and may be unethical. I'm not so certain about this, so let's take a look.

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:

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Le Mot Juste

Fri, 18 Jan 2008 10:21:05 -0600

When used deftly, words can be incisive tools of communication. Finding the best word to describe an emotion or idea tumbling around inside of one's brain should be an exciting and rewarding experience. Such mental exercises keep one's wits sharp while relaying information in a vivid, often memorable manner, such as when Winston Churchill described the expected role of the Allies in World War II: "In War: Resolution. In Defeat: Defiance. In Victory: Magnanimity. In Peace: Good Will." Notice how he distilled the essence of these powerful concepts down to just a few words.

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.

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Have a Seat in the Waiting Room - Sucker!

Wed, 16 Jan 2008 15:26:30 -0600

The following is a hypothetical advertisement seen on a community sign, let's say by a bus stop.

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:

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The Right Kind of Blood

Mon, 14 Jan 2008 09:00:31 -0600

"You should think it over - you'd feel so much better if you took a transfusion."

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."

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Where's Mao Zedong When You Need Him?

Fri, 11 Jan 2008 11:04:24 -0600

"Obesity now a 'lifestyle' choice for Americans, expert says"

"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:

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Three Hundred Easy Pieces

Wed, 09 Jan 2008 19:46:25 -0600

That last post was my 300th since I joined the ScienceBlogs community in August of 2006. I usually don't comment about my personal life but I must confess to a certain feeling of satisfaction on reaching the 300 mark, as I never thought I'd last this long. Since creating my alter ego over three years ago I have enjoyed setting him loose on the unsuspecting blogosphere. Coincidentally, over this same time period my practice has become much busier, not to mention my family plus my snooty dog who requires more attention than Marc Antony gave the Queen of the Nile. This makes it hard to find the time to write. I wish I knew how these über-bloggers spew out fifteen posts a day.

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?

"I Feel Your Pain. Now, Getting Back to Your Co-Pays..."

Tue, 08 Jan 2008 19:04:34 -0600

A study from Duke University reveals that oncologists who hear an expression of emotional concern from their patients respond with an empathic statement only 22% of the time. In other words, patients who share feelings of distress such as anger, discouragement or fear with their doctors are likely to receive no recognition of their suffering nor any emotional support in return. As a medical oncologist I find this embarrassing.

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:

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I Can Take the Pain - But Should I?

Sun, 06 Jan 2008 20:37:43 -0600

"Pain is inevitable. Suffering is optional."

Most all of us like to receive sound medical advice, even if we have no intention of following it. Perhaps this is why some experts relay information in a style reminiscent of filling the lifeboats of the Titanic. By trumpeting alarums for diseases deemed potentially life-threatening, doctors forget how easy it is to spook the general public. Hey, I'm scared enough as it is - God help my physician if I read a list of symptoms followed by the words "See Your Doctor Immediately!" I might just defenestrate myself to get to the emergency room before some orderly ties a somber tag on my "this little piggy went to market."

Now comes a list that will curdle the corpuscles of many a hearty soul, not to mention those with a skittish constitution. Read on if you dare.

"7 Pains You Shouldn't Ignore"
"Experts describe the types of pain that require prompt medical attention"

We all have aches and pains, but when should we start to worry? This WebMD article attempts to distinguish pains that could represent a life-threatening condition, and yessir, they do an efficient job. After reading it I had to curl up in a ball for an hour. I shall list the symptoms as they appear in the story. Here goes:

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"Run That by Me Again, Doc."

Sat, 05 Jan 2008 07:03:41 -0600

If you are an athlete or are just committed to exercising regularly, no matter what your age is, what do you do if your doctor tells you to stop it? I'll give you three possible responses:

1. "You're the doctor - if you say to stop running I'll stop."
2. "How do you know that this is the right decision? What's your experience with this?"
3. "Thanks, Doc!" (followed by this interior monologue [bowdlerized version]: "#### him! That fat ############. I'm going for a bike ride the minute I get home.")

The correct answer is below the fold.

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Smokers: Swish and Spit - If You Dare

Wed, 02 Jan 2008 12:18:46 -0600

A new study from Johns Hopkins shows that by sampling oral tissue from patients with a history of head and neck cancer doctors can predict with some accuracy the presence of a recurrence or of another primary tumor (presumably from the oropharynx). I found a couple of things about this report fascinating - first, the oropharyngeal tissue was not obtained by performing blind biopsies, which requires general anesthesia and O.R. time. Rather, the cells were collected by the patients themselves in a simple manner - gargling and spitting, and who doesn't love to do that, especially while watching a presidential debate? Actually the instructions were to scrape the inside of the mouth with a brush and then after gargling with 20cc of salt water, spit into a specimen container.

The second interesting fact is what the researchers did with the collected cells in order to predict the risk of recurrence.

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2008 Resolution No. 3: Uphold Magnanimity

Sun, 30 Dec 2007 06:45:19 -0600

"What Is Assertiveness?: Assertiveness is the ability to express one's feelings and assert one's rights while respecting the feelings and rights of others. Assertive communication is appropriately direct, open and honest, and clarifies one's needs to the other person."

"What Are the Benefits of Assertiveness?: Assertiveness affects many areas of life. Assertive people tend to have fewer conflicts in their dealings with others, which translates into much less stress in their lives. They get their needs met (which also means less stressing over unmet needs), and help others get their needs met, too."

"Aggressiveness tends to alienate others and create unnecessary stress. Those on the receiving end of aggressive behavior tend to feel attacked and often avoid the aggressive individual, understandably. Over time, people who behave aggressively tend to have a string of failed relationships and little social support, and they don't always understand that this is related to their own behavior."

"Passive individuals don't know how to adequately communicate their feelings and needs to others. They tend to fear conflict so much that they let their needs go unmet and keep their feelings secret in order to 'keep the peace'. Passive people aim to avoid conflict by avoiding communication about their needs and feelings, but this behavior damages relationships in the long run."

Feelings and needs...feelings and needs...what a crock. Every amateur psychobabblist is trying to get us to assert our feelings and needs, in a respectful manner, you know - wouldn't want to upset the poor soul who just cut in front of us, you know, need to think "win-win" and all that, you know.

I disagree - respectfully, of course. Anyone can master the ungentle art of being assertive. All one has to do is direct every waking thought and action on satisfying one's feelings and needs without irritating the other Olympian Gods who wander the aisles of the local Wal-Mart. Then it's off to bed with a hearty pat on the back: "I reduced my stress today and still met all my needs! I'm the best!"

magnanimous (adj.): 1. generous in forgiving an insult or injury; free from petty resentfulness or vindictiveness. 2. high-minded; noble. 3. proceeding from or revealing generosity or nobility of mind, character, etc.

I wonder what this country would be like if we promoted magnanimity more than assertiveness. Being assertive is easy. As a parent I do it all the time, e.g., announce to one of my offspring why his or her unbecoming speech or behavior is hurting my feelings and/or not meeting my needs. Easy, isn't it? Outside the house, though, I try to hold a more magnanimous view of my relationships with others. Even if it means I have to listen more, or wait more, or get home later at night, or even take more abuse, I am going to embrace a magnanimous attitude. Why? Time to state the resolution:

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2008 Resolution No. 2: Quit Prostituting My Taste Buds

Thu, 27 Dec 2007 18:04:09 -0600

In addition to heart disease, hypertension, cancer and diabetes, obesity has been linked to sleep apnea, job absenteeism, bad breath, even isolated findings such as an increased risk of dying from prostate cancer after definitive treatment.

Wouldn't most of us agree that it is in our best health interests to keep our weight down? Okay, and wouldn't all of us agree that we gain weight by putting things inside of our mouths and then swallowing them? And don't these things contain nutrients that, if swallowed in excess of what is needed for metabolism, are stored in our bodies as adipose tissue, thus leading to the health problem called obesity?

Now, here's the key point - how do we perceive the things we put in our mouths? As they touch the taste buds, do they bring us pleasure? Would we be thrilled to put items such as a handful of dandelion leaves in there, or a wad of Elmer's Glue, or maybe a nice cupful of Fido's kibble?

You see what I mean? We basically prefer swallowing stuff that our taste buds find delectable, and things that contain fat or carbohydrates (called "food") are what we swoon over. If we're fighting the war on obesity, junk food is our Mata Hari, ready to betray us for a few moments of ecstasy. I ought to know - I've been double-crossed plenty of times and have only myself to blame, although I still think it was worth the extra flab.

Well, it's time to put an end to this whoring around. I need to start treating my taste buds with more dignity and stop seducing them with every high fat, high fructose corn syrup temptress that happens to end up in my pantry. I now raise my right hand and pledge the following:

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