Thursday
“Steady, boys! Steady - wait until they get past that rock…closer…closer…not yet………NOW! FIRE!”
Gee, they make it seem so easy in those old war movies on late-night television. I’ve often wondered how movie soldiers kept from snapping at the moment of crisis. Would I have held my fire like a veteran, or pulled the trigger way too soon, thus ensuring me becoming vulture antipasti?
What, are you kidding me? I’m an oncologist - a specialist at firing away at the bad guys. To me the only crisis in a fight against the Tumor Batallion is if I run out of ammo. Keep those chemotherapy belts coming, boys - we’ll fight it out on this line all summer if we have to.
What a clever conceit! Too bad it’s just an adolescent fantasy. In real life, to take the above analogy further, the bullets launched against cancerous villains tend to spray all over the countryside wiping out Grandmas hanging their wash out to dry as well as one’s foxhole buddies. To put it in plain English, chemotherapy damages normal cells as well as malignant ones. This tends to be a discouraging word when it reaches the big brass at headquarters. One therefore needs to use discretion in letting loose a volley, let alone a naval gun bombardment, when deciding to attack cancer.
In other words doctors are obligated to use “good judgment” in deciding when to begin treatment. Many tumors require immediate if not urgent attention, not unlike a platoon cornered on a Norman field who must fight their way out or perish beneath the hedgerows. Sometimes though oncologists must resist the temptation to start chemotherapy. Sure, every one of us wants to look like we care and that we know what we’re doing, but there are situations where it makes sense to not treat the patient. I’ll give an example that occured recently - a patient with lung cancer I saw whose neck pain was worse than at the last visit. She has already received radiation and chemotherapy to the tumor in her neck, at a cost of moderate toxicity. Now she takes three pain pills a day. Should I start her on second-line chemotherapy?
Ich glaube nicht!. Her pain medicine usage is about the same as always, and her bone scan is only slightly worse than the old scan. My opinion is that it is not worth putting her through the side-effects of chemotherapy. The command therefore is: Hold your fire!
Ahem…I didn’t promise however that I would refrain from using all my weapons - just the ones that are the most dangerous. For your information, in the war against cancer dedicated researchers are producing smart bombs as well as blast-em-all-back-to-kingdom-come chemotherapy.
I put my patient on the epidermal growth factor inhibitor erlotinib, which has relatively minor side effects compared to chemotherapy. In war, this is like a laser-guided missile headed straight to the command and control center of the cancer cell.
This is only the beginning in the long, long march toward more effective treatments, but erlotinib and other targeted therapies do have one thing in common with cancer cells: they don’t fight fair. Good for them - and hooray for bullies, I say.
i have patients asking for tarceva! amazing. thanks for your comments on my blog. first-year fellowship is a rough one, but writing about it helps. i hope you don’t mind, but i quoted one of your earlier posts. hope you keep writing, as well.
Comment by OncoloGist — October 28, 2005 @ 3:24 am
Dr. Cheerful, speaking as a lung cancer patient (a never-smoker) on Tarceva, I call it my Magic Bullet. It’s working for me, since beginning taking 150mg beginning in May, my 3cm tumor has become a 1.2cm tumor, and stabilization of bone mets, and only a few, minimal side-affects. Yay for EGFR inhibitors!!! Go Genentech!!
Comment by Feisty — October 28, 2005 @ 5:38 am
The test for determining whether or not a patient is likely to respond to erlotinib will be a big help. They gotta get that thing perfected! What’s the status on that, Doc?
Comment by Feisty — October 28, 2005 @ 5:40 am
So with you on this one - can’t wait until Chemo side effects are a thing of the past…
Minerva
Comment by Minerva — October 29, 2005 @ 12:23 am
Okay, now I understand why you felt the way that you did when your entry was left out of Grand Rounds! Please forgive me! ;o)
Comment by DP — November 1, 2005 @ 5:57 am