Tuesday, July 05, 2005

Will chemo delay radiation treatment and make my breast cancer more likely to recur?


Influence of the time between surgery and radiotherapy on local recurrence in patients with lymph node-positive, early-stage, invasive breast carcinoma undergoing breast-conserving surgery: Results of the French Adjuvant Study Group (p 240-250)
Mohamed Benchalal, Elisabeth Le Prisé, Brigitte de Lafontan, Dominique Berton-Rigaud, Yazid Belkacemi, Pascale Romestaing, Karine Peignaux, Adel Courdi, Alain Monnier, Philippe Montcuquet, Marie-Josèphe Goudier, Christian Marchal, Philippe Chollet, Sophie Abadie-Lacourtoisie, Jean Datchary, Corinne Veyret, Pierre Kerbrat
Published Online: 9 Jun 2005


Monday, July 04, 2005

Kind of a complicated consult

The consult read, "d/c coumadin. Consult Dr. Onco-blog." Ok, so this was a weird reason to be called on July 4th, but I'm here. So the lady only speaks Italian. Ok, so we look up the language line. So far, I don't think any of the other four doctors who saw the patient thought to do this, at least not before they dictated their consults.

So the lady used to be on coumadin, but some fancy doctor in Beverly Hills took her off it. She reports some bleeding. She delegates decisionmaking authority to her daughter, though she herself has capacity, in my humble opinion. The translator explains to her in her naitive tongue that she will likely have a stroke if she does not submit to anticoagulation.

I wonder why someone with perfectly decent decisionmaking capacity would delegate like this. Turns out, her daughter is not particularly happy about having to make a decision for the mother. Looks like we have more than a language problem, we also have a communication problem.

So I tell the lady I'll talk to her daughter. That gets a strong reaction from the nurses. Apparently, this is the same daughter who refuses to let any insulin be given for blood sugar less than 250. I call the daughter, and she picks up on the first ring. At least she's around. She had me at hello...So I give my spiel about the coumadin. The lady had a stroke, she has paroxysmal atrial fib, and CHF. She's a setup for a stroke. I give her my disabled-but-not-dead scenario for stroke. She says she's gonna go back to Dr. Beverly Hills for an opinion, and that there's a new anticoagulant available. Sure, there are other anticoagulants out there, but none as good as coumadin in this setting, and there's no contraindication to coumadin. Sure, the patient's an old lady, but that alone ain't enough of a reason to withhold anticoag.

So this is basically denial--if we mount enough of what we think are cogent arguments, we don't have to listen to the doctor. It's a form of ignorance. Nobody would care, except that a lady might have a stroke over it. I told the daughter that anyone preventing this lady from having coumadin would be indirectly responsible if she had a stroke. The nurses appreciated that.

I'm looking up her CHADS2 score, and she has every point out there. She's a diabetic, CHF, HTN, old lady, prior CVA. She has a score of 6, so she would be 1/3 less likely to have an event per year. The benefit would be higher, but her risk is pretty high even with coumadin. The other thing is that she's a 50/50 COPD'er, so that gives her an adverse prognosis.

Maybe my attempt to bring clarity to a holiday consult on a high-risk patient is an exercise in futility. Maybe that's why I made my attempt with such relish.

Wednesday, June 29, 2005

Capecitabine for adjuvant colon cancer data hits NEJM this week

XACT trial
Twelves et al, NEJM 2005

Patients: Capecitabine 1250mg/m2 (d1-14 q21d) x 8 for 24 weeks (1004 pts) vs Mayo Clinic 5FU 425mg/m2 (d1-5 q28d) x 6 (983 pts)
Followup: 3.8 years
Results: Capecitabine numerically superior to, and statistically not inferior to, the 5FU for DFS. Survival was a little more likely, not to the level of statistical significance, in capecitabine patients.
Toxicity: about half the patients got diarrhea with the capecitabine, less than the conventional 5FU. All toxicities were less with capecitabine, except hand-foot syndrome. 17% of the hand-foot syndrome was grade iii-iv.

Criticisms: the study data was owned by the sponsor, not the researchers. The paper was reviewed by the company prior to submission to the journal. The toxicity data was only reported for 19 months after the enrollment of the last patient, while the median efficacy followup was for 3.8 years.

Tuesday, June 28, 2005

Recycled stories

You know, they're running out of superheroes to make movies about. First it was Superman. Then Batman. Then Spiderman. The X-Men got put in there. Now there's the Fantastic 4. Are these movies going to get increasingly obscure until we have no idea who these people are supposed to be? We're even to the point of remaking radio shows (like War of the Worlds). Are there no more original ideas out there for movies? They say there's only seven stories out there at all.

Thursday, June 23, 2005

Miscellaneous tips

Here are some clinical oncology pearls I was thinking about lately. This may increase over time. If there are patients or oncologists out there with interesting observations that might be useful to others, please share them.

1. Consider urea cream for xeloda patients. Urea cream, 40%, to hands and feet BID. I think they make it from urine. One patient related that the corn-huskers in Nebraska used to pee on their hands to remedy the dry cracked skin they got from shucking ears of corn (!) I have used it on two patients getting xeloda, and they both related marked improvement in their skin from it.

2. Focalin is a handy thing to use for cancer fatigue. Many patients are already on a lot of meds, so are reluctant to take one more. Also, I'm not sure it's more effective than ritalin, but there was a trial presented at ASCO this year that was well-received. I've tried it on a few people, and it seems to work 50% of the time. I start at 2.5mg per day, and increase slowly.

3. I have started advocating ice cream for patients will poor appetites. It is a lot cheaper and tastier than Boost, and it is packed with calories. It also is plentiful and available in interesting flavors. We have a lot of patients who have "responded" to ice cream "treatments".

4. I have two patients who have responded impressively to neurontin for nerve-compression pain. A brachial and abdominal nerve compression each responded very nicely to neurontin. It doesn't seem to help much for chemo-induced neuropathy.

More "tips" to follow; feel free to contribute your own. These "tips" are just printed here for your enjoyment and are not meant to diagnose or treat a particular patient. You may consider printing out something that looks interesting to discuss with your doctor or patient. These data are not peer-reviewed, just observations from my clinical practice.

Friday, June 03, 2005

"How much longer" part II

Surprising report from the ASCO annual meeting. One of the most meaningful presentations was about a survey of oncologists from the last annual meeting about their practices of having end-of-life discussions with their patients. I should make one caveat about the relationship between end-of-life and oncology: there are other fields of medicine that deal with death and dying as well. Surgery, cardiology, pulmonology. But there is a lot of death and dying in oncology--cancer is often a fatal disease. Oncologists get a lot of experience in sitting with patients and their families at the end of life, so it's good we attempt to study it formally. Probably a lot of people pooh-poohed this particular presentation because it was not "scientific," but I thought it was interesting.

The main results of the survey were surprising. One, the authors revealed that oncologists had a great amount of ambivalence about counseling patients and their families. Some even had a detached approach, and denied any emotion at all. The second finding was that many were reluctant to provide concrete numbers about how long the patient was expected to live, but that many of them would themselves want to know what their life expectancy is.

The authors reviewed other research that confirmed that (some) patients want to know the definite time-frame of their life expectancy.

I had this thought, that the speaker alluded to: It's hard enough to predict the life expectancy of someone who is healthy. A cancer diagnosis does not make it that much easier to predict how long a person is going to live.

I am starting to think that patients want to know a number about their life expectancy not because they've been conditioned to expect that information, but because they really want to know, operationally, for their lives. Maybe people have a morbid fascination with their own death, the way we all have a morbid fascination with the deaths of others (witness the enduring popularity of Titanic, and no, it wasn't the wooden love story that sold all those tickets).

So I've started sharing median survival information with patients. I don't know how much they really hear of what I'm saying. I'll say something like, if we took 100 people in your situation, half would live longer than 6 months, and half would not. There are some people who live much longer than 6 months. They probably go home and tell their family, "Doc says I got 6 months to live." This kind of pronouncement usually prompts more family to visit next time, which makes the visit take longer, but helps the patient at home.

I think this also speaks to the popularity (and necessity) of tumor markers. There are some patients for whom tumor markers are useless to track the progress of their cancer. But there are some patients who have residual disease for whom tumor markers are well-correlated with the disease burden. Doesn't mean they'll die sooner, but it is a tangible way of keeping score. Morbid fascination or vital information? I'll have to tell you when I get cancer myself.

Sunday, January 23, 2005

Oncology theme music

If anyone can think of any other songs, let me know.

Garbage: Only Happy When it Rains
Harvey Danger: Flagpole Sita
Smiths: How Soon is Now?
Radiohead: Creep
P.J. Harvey: Down by the Water
Moby: Extreme Ways
Blue Oyster Cult: Don't Fear the Reaper
Aimee Mann: Wise Up (also, One is the Lonliest Number, but I draw the line at songs used for dramatic effect in Shrek 2).