Archives of The Cheerful Oncologist, Volume 2

I ran into Smilin’ Joe the other day and asked him how business was down at the lot. He laughed loudly, perhaps a little too loudly, and gave me an answer I never thought I would hear from a car dealer. I was enjoying a double-shot-hazelnut-chocolate-frosty-latte-with-whipped-cholesterol at the time and hoped to avoid getting involved in a long-winded story, but since the couch I was perched on had an open seat, short of yelling “Fire!” there wasn’t much chance in escaping.

It turns out that Joe’s reply was the most interesting thing I heard that month.

What he told me was that the Federal Commission on Automobile Prices recently released the results of a study on the way cars are sold in America, and this report became the focus of a series of stories in the east coast newspapers, which led to the publishing of some rather unflattering editorials about car dealers, after which a prominent member of Congress gave a blistering speech on the House floor, which led to the formation of a special Sub-Committee, who investigated further and found out this shocking bit of news:

When innocent consumers in this country buy a car, the dealer makes money off of the sale, as does the manufacturer. It turns out that (after a multi-million dollar study of the situation), the buyer pays more for a vehicle than it actually cost to make.

So I turns to Joe and I says to him, “What’s all the hubbub, Bub?”

He said that because of all this bad publicity he is now under pressure to either sell his cars for less than he purchases them for, or to at least stop pushing expensive new vehicles on his customers and sell them older used cars.

“What’s wrong with selling used cars?” I asked. “Don’t you make plenty of profit off of them?”

Joe then gave me a look I haven’t seen since I asked my high school’s homecoming queen for a date, or was it the look my dog gives me whenever I fail to produce her evening meal in a timely fashion? At any rate, he replied that the “experts” studying this phenomenon have recommended that people really ought to drive cars from the 1960s to late-1970s, as they have determined that this is the most cost-efficient way to provide individual transportation for those who need such mobility.

“Really?” I said. “Have you started this yet? Are you selling old cars now?”

I could see his grip on the cardboard cup in his hand tighten and suddenly had visions of me arriving at work in cafe-au-lait trousers, but he managed to speak in measured tones. The problem, as he stated it in extremely clear wording, was that car shoppers don’t want to drive vehicles without airbags, anti-lock brakes, CD players, power windows, et cetera. They aren’t stupid, and can see that over the past three decades automobiles have become safer, more reliable and more enjoyable to drive. Despite the daydreams of gurus and bureaucrats, consumers are not interested in going back to a time when everything was cheaper except the quality of their lives.

Suddenly I felt that Joe and I had more in common than our taste in sport coats. I thanked him for this bit of news and we both went our separate ways, each considering our unique role in this drama called life in America, each of us mysteriously linked together in the quest to push this obscure planet on to its destiny - a destiny lying too far in the future to agonize over, but not too far to contemplate with absolute astonishment.

“The way oncologists are paid might influence the choice of drugs they use in chemotherapy, according to researchers from the University of Michigan and Harvard University.”

Hmm…there’s an eye-catching headline for an oncologist…wonder what they mean by this…

“Payment methods do not seem to affect whether doctors favor chemotherapy over other treatments, the study’s authors said. But once they decide to use chemotherapy, the current payment system appears to prompt some doctors to use more expensive drugs. The authors wrote, ‘Providers who were more generously reimbursed prescribed more costly chemotherapy regimens to metastatic breast, colorectal, and lung patients.”

RED ALERT! RED ALERT! Hit the brakes, Myrtle! Go to DEFCON 1, Commander! Put out an APB for a middle-aged man in a white coat…he is armed with a black tube and small flashlight! Danger, Will Robinson, danger!

So using more costly “chemotherapy” drugs increases the reimbursement to the “provider,” eh? This “study” therefore implies that since using cheaper treatments lowers the revenue paid to an oncology practice, the doctors have a conflict of interest and are biased toward giving “expensive” treatments rather than “cheap” ones. Could there be another possible reason for such a pattern, or is this simply another example of an egregious dereliction of the altruistic spirit the anointed demand in order to save mankind from itself?

“Because there is little evidence that one chemotherapy drug works better than another, ‘the physicians have more control over the agents chosen,’ one of the authors, Joseph P. Newhouse, a professor of health policy and management at Harvard, said in a press review.”

That statement, ladies and gentlemen, raises the hackles of the corporate owners, foreign investors and political comrades of this blog, not to mention all our friends in the olive oil business, if you know what I mean. In rebuttal, let me recite some statistics comparing one “chemotherapy” drug to another in the treatment of the three cancers mentioned in the article, using the outcome of overall survival as a measurement of effectiveness of each regimen, then let the reader decide which treatment they would prefer to take. These statistics refer to patients with metastatic disease for which cure is not possible:

Lung Cancer (non-small cell)
cheap regimen: etoposide/cisplatin; median overall survival (MOS) - 9 months
costly regimen: paclitaxel/carboplatin/bevacizumab; MOS - 17.7 months

Breast Cancer
cheap regimen: cyclophosphamide, doxorubicin, fluorouracil; MOS - 12 to 24 months
costly regimen: docetaxel, vinorelbine, bevacizumab, trastuzumab, et cetera; MOS - at least an additional three months, but we suspect the MOS is on its way to 3 to 5 years based on early data

Colon Cancer
cheap regimen: fluorouracil/leucovorin; MOS - 12 months
costly regimen: oxaliplatin/fluorouracil/leucovorin/bevacizumab; MOS - 22 months

Now if we are not particularly interested in prolonging our life by all means we should ask our oncologist to give us the cheapest anti-cancer treatment available; in fact, using the reductio ad absurdum, in order to avoid wasting our country’s precious financial resources we actually should decline to be treated at all. Now there’s a way to save Uncle Sam some serious dough!

This reminds me of a parable - the story of the publicity crisis at Smiling Joe’s Used Car Lot, but that will have to wait until part two of this post, as I have a plane to catch. Until then:

Stand tall, look ‘em straight in the eye, smile and show ‘em you’re not afraid of anything!

The rain was still falling, but the darkness had parted in the west, and there was a pink and golden billow of foamy clouds above the sea.

“Look at that,” she whispered, and then after a moment: “I’d like to just get one of those pink clouds and put you in it and push you around.”

F. Scott Fitzgerald, The Great Gatsby, 1925

If we think of a serious illness as a storm, pummeling our bodies with humiliating downpours of pain, pinning our arms and legs down with gusts of demoralizing fatigue and petrifying us with sudden claps of fear, then what happens if, by the grace of God and modern medical care, we get better?

The storm overcomes us, then the storm passes on. Whether it is a gradual withdrawal like a long spring shower or an explosion of sound and fury that hits fast and then just as quickly plows on toward the horizon, once the sickness passes we peek out from our hospital rooms, standing on steadier legs, perhaps anticipating a good meal for the first time in weeks. As we feel better our world becomes larger once again. The forecast reads bright.

The illness passes and the darkness parts in the distance. We come to the window as Daisy Buchanan does in the novel and see the transition unfolding before our eyes. The burden over our heads has moved on. The barrier that separated us from the giddy courage crouched within our hearts, that smothered the flashes of brazen, aching desire we cannot control, is gone, and now we move as if awakened from a deep sleep. We are released from the self-absorption of our symptoms, free to once again reach out as far as our arms can take us - all the way to the clouds if we dare.

If disease is a gray fog or a wailing bank of blackness driving us into hiding, then recovery is a lovely sunset swirling with pink and orange clouds, bringing us outdoors where the night breeze caresses faces leaning toward the west.

How wonderful it is to be well again. As the indigo of night drifts downward and crickets hiding in the grass stir to life, we suddenly yawn and rise, overcome with a yearning for sleep. Only a lone shadow remains on the veranda, silently watching the nothing that rules all once the sun is gone. His back is to the doorway as he settles in under the lattice of stars.

“How long are you going to wait?”
“All night, if necessary. Anyhow, till they all go to bed.”

Perhaps someone will approach him and politely inquire about his health: is he feeling better? Wouldn’t he like to turn in now?

“But I didn’t call to him, for he gave a sudden intimation that he was content to be alone - he stretched out his arms toward the dark water in a curious way, and, far as I was from him, I could have sworn he was trembling.”

Why would anyone, after surviving the hardship of illness, refuse to get some well-deserved rest? What is in the night sky that tempts this weary one to stay on?

“Oh, I’m not one of the patients,” he replies. “I’m the doctor who cared for them throughout their illness.”

“But why are you still up?”

“I’m waiting for the next storm.”

The editors, staff writers and sales personnel of this web log are always being admonished by the boss to take better care of their health. This sometimes leads to conflicts when employees are discovered smoking behind the dumpster out back, or when the C.O. finds messages taped to the vending machine that say “Please please make the bottom row all Famous Amos cookies.”

Always one to lead by example, The Cheerful Oncologist has strived to adopt a healthy diet (albeit punctuated by occasional lapses of judgment), along with regular exercise and at least an attempt to retire before the nightly showing of The Sopranos on HBO. In fact, he has developed quite a knack for researching ways to gain an advantage over his neighbor when it comes to avoiding heart attacks, cancer, or…or…or…now what was that third calamity? Oh well, it will come to me later.

Yessir, from green tea to white tea to red wine to peachy salmon par excellence, the boss here has gone out of his way to fortify and sanctify his body against dry rot, putrefaction and termites. Why, he even had his homocysteine level checked and, finding it floating above the upper limit of normal, started himself on high doses of a folic acid supplement in an attempt to lower this level and prevent the forest fire of a myocardial conflagration.

“You know we don’t have definitive proof that taking folic acid reduces the incidence of an M.I.,” said his long-suffering personal physician, a man undoubtedly destined for sainthood for his years of giving advice to this neurotic Gordian knot of an oncologist.

The C.O. laughed at such Wally-Cox-like hesitation and kept on taking folate, along with aspirin, oatmeal, Australian shiraz, soy protein, Tabasco sauce and Evening Primrose Oil, although he mistakenly took this in the morning. He posted testimonials from satisfied customers on the bulletin board and held town hall meetings with his staff where he would cajole them to stop living like it was 1910 and get with the modern program to ensure the benefits of a long life.

Soon the whole office was on folic acid, and the Doc noticed a definite new perkiness in his employees as they skipped along the hallways. He closed the door to his office and spoke to the large portrait hanging over his desk.

“You see what I can flush out with a little push? You just wait and see - someday they’ll consider me to be just as big a hero as you were.”

He sat down, fired up his computer and clicked on the headlines, where he read the following announcement:

“Folic Acid Supplements Won’t Lower Heart-Attack Risk”

“Both reports will appear in the April 13 issue of The New England Journal of Medicine, but were released early to coincide with their presentation Sunday at the meeting of the American College of Cardiology in Atlanta.”

The next morning the following notice was tacked to the message board outside of the boss’s office:

“Never mind.”

“Individuals who have a genetic variation associated with slower caffeine metabolism appear to have an increased risk of non-fatal heart attack associated with higher amounts of coffee intake, according to a study in the March 8 issue of JAMA.”

My God, is nothing sacred? It’s already bad enough that some of the more hapless members of our species who, in a bit of heavenly monkeyshines, were born with humiliatingly defective genes now coming to life like Frankenstein’s monster and guaranteeing a life of high cholesterol and other hereditary predicaments. But coffee? Dear, slick, hot, compost-heapy, slurpy, nutty, jangle-your-nervy-nerves coffee? Are you telling me that I might have to risk a heart attack every time I order up a double choco-peppermint caffe’ macchiato with whipped cream? Where am I going to get my daily jolt if not from coffee, and don’t tell me to forgo the caffeine. I tried that once, with devastating consequences.

Must we persist in this relentless search to find every “genetic variation” hiding within our DNA foot locker? When will some respected authority finally announce that it’s time to stop punishing the human race for being alive and let us eat and drink what we want? Heaven knows we all want to live long enough to become a burden to our children, but don’t you think it’s time we put our personal habits into the proper perspective? It seems that the know-it-alls are on a mission to take all pleasure away from anyone who lives long enough to become a legal adult. First it was laudanum, then cocaine, then absinthe, followed by marijuana and alcohol (oh, wait - booze made it back into our good graces in ‘33) - and now caffeine?

Mama mia, what will be next?

Unfortunately, as a respected member of the medical community I feel it is my duty to set a good example to my patients. Hell itself will freeze over before I give up caffeine, let alone a genetic predisposition to colorful language, but as penance for all my prior sins, and as a public service to my readers, I grudgingly announce that I am making the following changes in my lifestyle:

1. I promise to get no less than eight hours of sleep per night. (Of course this means that the dog, being denied her punctual 3 A.M. trip to the back yard, will now whiz all over the carpet while I slumber).

2. I hereby eschew all coffee, no matter how hard the baristas work to disguise it as a frothy melted Milky Way bar, and will drink only virginal tea leaves harvested from the shady side of the Himalayas during a full moon.

3. Exercise is now part of my daily routine, not just something I get after a hot dog stand owner yells “Stop thief!” (Do you know how hard it is to run and spread on mustard at the same time?)

4. The following potentially detrimental habits, although not yet revealed to shorten one’s life, will now and forever be banned from my person, lest I read about them in Newsweek next year and drop dead from the shock. They are: public flatulence, a cavalier attitude when applying deodorant, comb-overs, an excessive affection for garlic, a certain lackadaisical attitude about stepping in doggy doo-doo, shaving off back hair, and last but not least snapping one’s fingers to the beat in front of the kids when “Knock Three Times” comes on the radio.

Genetic variations be damned, I’m going to do my part to live to be a hundred years old! I just hope they’re still playing reruns of all my favorite shows if I make it that far. After all, what are we working so hard to live so long for, if not for the things we value most?

“Act with kindness, but do not expect gratitude.”
-Confucious, 551-479 B.C.

Please read the following problem, then select the one best answer to the question that follows:

A 52 year-old post-menopausal woman is diagnosed with infiltrating ductal carcinoma of the breast. Her tumor size is 3.5 cm and angiolymphatic invasion is present. She undergoes a lumpectomy and sentinel lymph node biospy, and two out of five nodes contain metastatic carcinoma. No further disease is found on routine imaging studies which include fusion PET/CT imaging. Her tumor is estrogen-receptor positive, progesterone-receptor negative, and HER-2 is overexpressed by fluorescent-in-situ-hybridization (FISH).

She is treated with adjuvant dose-dense chemotherapy using sequential doxorubicin, paclitaxel and cyclophosphamide, followed by radiation therapy and a 52-week course of trastuzumab monoclonal antibody therapy. A five-year course of the oral aromatase inhibitor letrozole begins upon the completion of radiation therapy.

The patient develops the following side-effects during her treatment: severe alopecia, nausea, anemia, one episode of fever associated with neutropenia, fatigue, numbness of the toes and feet, diffuse myalgias from pegylated filgrastim injections requiring the use of oral narcotics, erythema and dry desquamation of the skin over the breast.

One year later, her oncologist states that she can now have her portacath removed and won’t have to return to the office for three months. He offers congratulations to her on successfully completing all of her intravenous therapy and says, “Hooray - you made it through!” The patients replies, “Thanks to you, Doctor. You and your staff worked so hard - you are all the greatest.”

The correct response to this compliment is:

A. “Thank you. It’s very kind of you to say that.”

B. “Hey - that’s what we’re here for.”

C. “I know - I’m lucky to have such wonderful nurses.”

D. “It was a long haul, wasn’t it? Did you ever think it would end?”

E. “Well, I couldn’t let you down now, could I? I don’t want to ruin my reputation!”

The proctor will now collect the answer sheets. No peeking at your neighbor’s paper, now. Are all the sheets in? Good. Now, the correct answer was:

F. NONE OF THE ABOVE.

Did we fool you? Perhaps you’re wondering why The Cheerful Oncologist rejected all of the above replies to his grateful patient and came up with a different answer. Pehaps you are also wondering why you didn’t pick the winning numbers in last month’s 360 million-dollar lottery, as our narrator is. Never mind that - here is what I said to my patient:

“You did all the work, not me. Think of what you went through last year as a crucial airplane trip out of a dangerous country to the land of good health. You owned the airplane and you were the pilot. The fact that you made it safely home is due to your efforts, not mine. I was just ground control, sending up directions and messages of encouragement to you. You made all the sacrifices and now, with a little more help, you’ll get to enjoy the rewards of this investment in your future.”

As part of our continuing series on the mysteries of the medical profession we bring you the following tale of a sad situation when a doctor’s heart is no longer in his work. For those interested, parts I, II, and III of the “Hidden Lives” series can be found stuffed somewhere in a drawer in the archives of this website, which is just another way to state that the blogmeister is too lazy to link to them.

[Editor’s note: the following observations were made by a patient living in an average city somewhere in America.]

“I went to my doctor today and after leaving his office had the most amazing revelation.”

“What - you discovered that you had left your trousers hanging on the back of the exam door?”

“Har, har. No, not that, silly. It’s just that I realized that he doesn’t enjoy his work anymore. I think he’s on his way to becoming a victim of doctor burn-out.”

“I suppose you had to wait forever to be seen.”

“No, he came in right after the nurse closed the door. He was as punctual as always.”

“So did he pay any attention to you or just shuffle his papers?”

“No, he asked me about my pain meds and such. He even noticed that I have lost weight and wanted to know how my appetite was - and my swallowing.”

“What about the scans you had last week. Did he know the results?”

“He did. He reviewed the reports with me and told me what things I should be on the lookout for over the next few weeks. He always is thinking ahead of what might go wrong. He says I need to ‘Be Prepared’ just like the Boy Scouts.”

“What’s wrong with that? He sounds like a good guy to me. Why do you think he’s burned out?”

“I was in and out of that room within five minutes, I swear. It seemed like he was in a hurry to move on to the next patient or whatever was next. That’s not like him.”

“Maybe he was just behind schedule, or had a bad night. Doctors are only human, you know.”

“Maybe, but I got the impression that he just didn’t care about my case. It seemed like he was just going through the motions. I felt bad all the way driving home.”

“Why don’t you ask him about this the next time you see him?”

“Well, this isn’t the first time I’ve noticed this change, and frankly I’ve decided to switch doctors. My sister wants me to go to the Medical Center to see an expert there, and I’ve already made an appointment for next week.”

With the reader’s kind permission The Cheerful Oncologist would like to weigh in on the above vignette. Without further ado then, here is his astonishingly insightful and sagacious commentary:

I sympathize with both the patient and the doctor in this story. The doctor mentioned above does seem caring, but the fact is he lost a patient today because of his detatched mien and hurried pace. The practice of modern medicine is more intense now than ever, and the pressure placed on physicians is enormous what with obeying Kafka-like rules and regulations, trying to please the high and higher expectations from patients, and second-guessing treatment decisions under the threat of malpractice lawsuits. The potential for physicians to burn-out and lose their desire to pursue excellence, let alone mediocrity, in their daily work is as great as ever. Since no one wants to have a lost soul for a doctor, it behooves us here at T.C.O. to provide a little helpful advice to patients who just might be wondering whether or not their local practitioner still has enough fuel inside to keep the fire burning bright, to ward off the deadly chill of apathy or anger.

Rather than list the signs of doctor burn-out (after all, this is supposed to be a cheery rest stop for voyagers of the blogosphere), let us instead identify the clues that one’s physician is definitely not embittered, worn-out or fed up. These characteristics are as follows:

1. The doctor uses your actual name when addressing you, not some idiotic condescending title like “Sweetie,” or “Buddy.” What, has he mistaken you for his pet dachshund? An even worse scenario is when the doctor never calls you by name, as if you’re completing a transaction in front of a fast food counter.

2. The doctor makes eye contact with his audience, whether it be one person or a dozen, and maintains it throughout the visit.

3. Whenever feasible, especially when the news is not good, the doctor sits down before beginning a discussion.

4. The doctor asks questions about his patients’ lives - their children, their vacations, any good books they might have read lately. He is genuinely interested in his patients, no two of which are alike. For World War II buffs like myself, this is a great way to learn a little bit of history from one who was actually there, if not personally court-martialed by General Patton for not wearing a proper uniform.

5. Lastly, the most important clue of all in my opinion is that the doctor smiles, chuckles, makes you laugh, uses humor to break the ice, to form a bond, to provide encouragement or diffuse anger, to charm the crowd. When they say that laughter is the best medicine they aren’t just referring to patients. The doctor who truly loves his job cannot help but see how he has the unique opportunity to bring a grin to someone who just might be in desperate need of one today.

As we now return you to your normal lives, please remember these words of wisdom - “Fight burn-out now - tell your doctor a joke today!”