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Innovation and risk-taking at the heart of better medicine
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This past Memorial Day weekend, I thought about my uncle, a veteran of the Korean War, who has been diagnosed with cancer. I’ve received a few calls from my aunt and have watched the painful process of cancer diagnosis and prognosis unfold in slow motion.
My uncle is 74 years old, with diabetes and some mild renal insufficiency, but otherwise in good health. He always watched what he ate, never smoked, maintained an exercise regimen and has been in fairly good shape. During the past week or two, he noticed some gnawing stomach pain. He then had at least two episodes of dizziness, lightheadedness and near-fainting, so he sought medical attention.
My aunt called me from his hospital room to tell me about this and to let me know about the tests that had been done so far. She knew that he had a procedure in which “they looked at his stomach” and “saw an ulcer.” She also knew that he had a CT scan, and she had obtained the report to tell me what it said. Struggling to pronounce some of the words, she was able to say “multiple hypodensities in the liver,” “soft tissue mass near the pancreas” and “suspicious for metastases.” Although he didn’t yet have a pathological diagnosis, my aunt knew what this all meant, as did I. It didn’t help that one of my uncle’s nurses offered, on one of the first nights, that “we know he has cancer, now we just need to figure out if it’s in his brain.” My aunt and uncle could guess the same thing, of course, but the words were harsh.
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On a recent call, my aunt put my uncle on the phone with me. Why did this happen, he wanted to know. Cancer wasn’t in the family and he’d tried to live a good life. “When I was in the Army,” he said, “they used to give us APCs, all purpose capsules; I think it was probably aspirin. I guess there’s probably not an APC for this, is there?”
Treatment costs vs. benefits
I struggled later with what I felt appropriate telling my aunt — and what I didn’t. I could have a discussion about different kinds of cancer, confirm that the oncologist’s recommendation was sound, and talk about the role and benefits of palliative chemotherapy once a specific diagnosis was known. My aunt and uncle were realistic about all of this. They were grieving about the implications of the diagnosis, but “didn’t want treatment if it wasn’t going to help.”
I had to be honest with myself: How much would I tell them, or confirm secondhand, that the treatment that would be offered would help? They had insurance — not the best, but not the worst — and lived modestly. They owned a small house. I remembered a front-page story in my local paper about spouses who had lost everything they owned, even gone into debt, to try to finance chemotherapeutic regimens (and the ensuing extra medical care) that added some extra months of life at best.
I imagined my aunt in a situation similar to this, and how my uncle would feel as he worried that this might happen. Should I talk with them about the costs of care, or leave this to someone else to explain? I felt helpless and inadequate, not just on a personal level, but in my profession in general. What exactly did we have to offer?
Big picture thinking
I started to think about Siddhartha Mukherjee’s wonderful book, The Emperor of All Maladies: A Biography of Cancer. I had heard about this book in newsletters and journals and was intrigued by the idea of a (relatively) recent fellowship graduate attempting to construct a biography of cancer. Having gone through fellowship recently, I knew how life-changing the first years of any clinical oncology fellowship are, and how everyone who goes through it reacts differently. I wanted to read Dr. Mukherjee’s epic as the reflections of a journey that I (and many others) had also traveled, and I was struck by the nearly universally positive reviews. I didn’t realize how moved I would be by his book.
Dr. Mukherjee attempts something unbelievably ambitious in the space of several hundred pages; he tries to discuss nearly all of the major cancer-related historical recordings, political achievements and scientific discoveries of the past several thousand years, all while imbuing “cancer” with the personality of an adaptable, inventive and altogether human organism. Throughout, he develops a narrative about the success and limitations of anticancer strategies in the last century and his ideas about the way forward, as well as realistic expectations for future achievements. I think it is a wonderful read (as do many others, including Harold Varmus, MD, NCI director and Harry Jacob, MD, HemOnc Today Chief Medical Editor) and strongly recommend it.
Dr. Mukherjee’s book has forced upon me a wider perspective that is sometimes hard to find when performing the duties of an oncologist. I am sure that my uncle will benefit from advances in both therapeutic and supportive care for his disease. These benefits, though, are modest in the grand scheme of things. We don’t yet have an APC for metastatic cancer. His disease won’t be cured. His life may be prolonged, but the amount of extra time is not so likely to be measured in years. Despite the best that palliative care can offer, he may still suffer. And my aunt may struggle trying to pay for it all, before and after his battle is over.
Despite this seemingly gloomy story, I am not a nihilist about our future in oncology. For me, the central lesson in Dr. Mukherjee’s book is not so much about the drive toward targeted anticancer therapy — although I would surely welcome his utopian vision of anticancer cocktails to keep malignancies at bay. Instead, I was inspired by the creative and dedicated physician-scientists who took risks and pursued theories long before they would become accepted in common practice.
To be sure, there are many cautionary tales along the way, from the ultra-radical mastectomies of the 20th century to bone marrow transplants for breast cancer. But there are great successes too, many of them from researchers who were not highly established at the time of their initial insights. The greatest wins have rarely come from incrementalist approaches or building better mouse traps based on modestly effective strategies. With true inspiration, innovation, and risk-taking in research and treatment, we might be able to better understand the therapeutic outliers and miraculous cures that exist in all of our practices.
William Wood, MD, is assistant professor of medicine, division of hematology/oncology, at the University of North Carolina, Chapel Hill. Dr. Wood may be reached at william_wood@med.unc.edu. Disclosure: Dr. Wood reports no relevant financial disclosures.