I stumbled across this terrific article titled:
How Doctors Die by Ken Murray a FP at USC.
It is largely anecdotal, but is a really an interesting perspective on how at least some physicians choose to forgo futile end-of-life treatments because they know the limits of modern medicine first hand.
Also Enjoy:
Octogenerian’s Letter to Santa
Add Some Red to Black Friday and I’ll give some Green to the American Cancer Society
Millions of Americans shop for Christmas gift bargains on Black Friday every year. I encourage you to give a gift on Black Friday that costs you nothing more that a little time, and which can help you feel you have truly given life and hope during this holiday season.
My readers will know that I’m a big proponent of regular blood donations. Kay, my wife has ovarian cancer and has been a recipient of donated blood when her blood counts get low from chemotherapy. Cancer patients are among the highest users of donated blood products from red blood cells to platelets. I’m donating regularly to be sure our family puts more blood into the blood banking system than we take out. I want you to join with me on the Friday after Thanksgiving this year by paying a visit to your local blood donation center. There are even potential blood donation health benefits.
I’m putting out a challenge to readers, your friends and anyone else you can contact. Black Friday is a day when many of us are out and about shopping and getting ready for the holidays. The holiday season is also a time when blood donations tend to fall behind need. Here is the challenge:
I’ll donate $1. (up to $1000) for every comment to this post or tweet me @DoctorPullen telling me that you have or intend to go to your local blood donation center on Black Friday and donate blood. $1. may sound like chump change, but I want to get 1000+ people who would otherwise not donate blood to do so this Friday. We are in a world of easy communication, and I bet everyone who reads this knows 10 people who are in a position to get to their blood donation center this black Friday and donate. Just do it!
Take a break from shopping, get off your feet, and relax while you give one special holiday gift. Use the twitter or facebook links to send this off to your friends, tell your coworkers, shout from the roof tops, whatever but let’s make this Black Friday blood red with our generosity.
My daughter, son and I plan to go to the local Cascade Regional Blood Bank center in Puyallup Friday. I checked and they are open 7:30 AM – 5:00PM. I’ll try to keep a counter going on the site to let you all know how we are doing.
They Turned Me Away Today
Egg on my face. I went today to donate, but was turned away because I went to Belize on vacation a couple of months age, an area with malaria exposure potential. I’m now ineligible for a year, joining a majority of the rest of Americans. If you are among the 37% who are eligible donors get to your blood donation center and give. Keep our blood supply safe and plentiful. Happy Thanksgiving.
This post is in appreciation of the 35th anniversary of the first “Smokeout”, actually the November 18, 1976 “Don’t Smoke Day” (D-Day) in San Francisco sponsored by the California Division of the American Cancer Society which received national (all 3 major national networks at the time ) and became a national event thereafter. The third Thursday of November each year, just one week prior to Thanksgiving is the Great American Smokeout. About 45.8 million Americans still smoke and most studies show more American smokers would like to quit smoking than those who don’t want to quit. Here are some great reasons to quit:
1. Retire Early(or take a nice vacation every year) on the Savings: If you smoke 1 pack of cigarettes a day for a year, at an average cost in Washington State where I live and work at the average cost in WA of $9.89/ pack you spend $3609.85 a year on cigarettes alone. If saved the 3609.85 annually and invested it at only 4% you would have $111,794.17 in 20 years. It would be more if you invested daily or monthly. Quit smoking now and you can be a long way towards a retirement fund. You may also live to retire. (I admit Washington is the second most expensive state to buy cigarettes in the U.S.)
2. It Stinks: Any non-smoker can tell you that they can smell the odor of cigarettes on your clothing, hair and body from several feet away. By quitting smoking you will avoid smelling repulsive to the majority of others in society.
3. Live Longer and Better: The average smoker dies 7 years earlier than the average non-smoker, and estimates of the time lost per cigarette smoked is 7-10 minutes per cigarette. The whole issue is really much more complex that this, but without doubt quitting smoking can add significant time to the average person’s lifespan.
4. Better Sex for Longer: Smokers have a much higher incidence of peripheral vascular disease, and erectile dysfunction is often the result of vascular disease. Quitting smoking can lead to a better sex life for many smokers.
5. Dying of COPD is Among the Worst Ways to Die: This is my personal opinion, but I’ve taken care of people who have died nearly every common cause of death. Respiratory failure has to be among the least desirable way to die. Being essentially immobile, gasping for air while on oxygen for months or years, and finally dying of a respiratory infection that leads to inability to breath is not among the ways I hope to die.
6. Get Your Kids/Grandkids/Spouse/…. Off Your Case: Nearly every smoker I see in the office comments that their loved ones are hoping the get them to quit, and often annoying them with encouragement and pestering. Why not change all that to congratulations and positive reinforcement after you quit?
7. Feel Proud that You Quit: Most smokers would like to quit smoking. Most who do tell me that they are happy and proud that they were able to quit. Join the ranks of proud ex-smokers.
Please leave comment with more and better reasons to quit. I’d love to have this post be a place for smokers to find the right reason for them and quit themselves. There is no time like today!
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You may also enjoy:
Actual Causes of Death in the U.S.: Not What You’d Think
The controversy over PSA testing is tough. Nobody wants to hear that although prostate cancer is the second leading cause of cancer death in men behind lung cancer that there is no good reason to believe that PSA testing leads to either longer or better lives. It is a tough dilemma. Death from prostate cancer is not good. Men sometimes die after long, painful illness with metastatic bone cancer and a wasting painful death. Everyone including me wants to believe that early diagnosis must be good. Unfortunately the evidence just does not lead you to that conclusion. You may have enjoyed my last post on Prostate Cancer Screening, “Don’t Do Something: Just Stand There” and in todays New York Times is a very thourough historical and analytical article outlining the controversy of PSA screening. It is full of emotional quotes by advocates and skeptics. Also is a link to Dr. Kenny Lin’s latest article on the subject also. These make a good read for anyone considering PSA screening.
Can Cancer Ever Be Ignored? by Shannon Brownlee and Jeannie Lenzer
I especially like the article’s visual. It raises the seldom stated but often considered axiom that every good primary physician knows: If you don’t want to know the answer, don’t ask the question.
Dr. Kenny Lin, a key player in the PSA debate as the ex-USPSTF point investigator on the PSA screening dilema who resigned in protest of political pressure to withhold new recommendations to make PSA screening a grade D (as in don’t do it) for PSA screening in healthy males that was based on the best available evidence but was politically unacceptable writes another excellent discussion of the topic:
The Meeting that Wasn’t Revisited by Kenny Lin MD.
Stay tuned for the latest on this controversy. Subscribe to DrPullen.com to not miss a post. You can choose to subscribe to all posts, or just by category. Just enter your e-mail address in the subscribe area at the right.
NOTE THAT SINCE THIS WAS POSTED THE USPSTF HAS POSTED A PROPOSED UPDATE TO THEIR RECOMMENDATIONS FOR PSA TESTING FOR MED AS A “D” RECOMMENDATION, i.e. RECOMMENDING AGAINST USE OF PSA AS A PROSTATE CANCER SCREENING TOOL.
by Christina Lufkin, Hospice Volunteer and Author.
What is Hospice?
Hospice is not a death sentence. It is an opportunity to live life to the fullest until you die.
I have been a Hospice volunteer since 1994. It is my passion. To be of service to others during such an important and intense time of life is an honor. The more I give, I am repaid tenfold. In order to qualify for Hospice a patient must be diagnosed with a terminal illness that if it were to progress at the normal rate, would only have six months to live. To be eligible a patient can’t be involved in treatment to try cure the illness. Their doctor must write a referral for the patient to be evaluated for Hospice care.
Once enrolled, if the patient lives to the six month timeframe they can be evaluated and reinstated in the program. Hospice provides many services that assist both the patient and the family. I have had many conversations with family members and friends of terminally ill patients who were anxious because of unresolved issues with the patient or because they just felt they needed to share something and had not done so. I always encourage them to make time to talk about the issues. It will be too late once the patient has passed. If left unresolved these situations can lead to the survivor feeling regret, sadness, guilt or frustration. Grief is natural but adding the pressure of not talking openly before someone dies can make the grieving process much harder.
Many patients have talked with me about the importance of relationships in their life. They have never expressed regret about wishing they had more money, possessions or fame. It is so important to most people to know that they don’t have any unfinished business, which allows them to pass peacefully. Once a patient has been diagnosed with a terminal illness, Hospice is the best way to have their wishes met. The Hospice team; Nurse, CNA, Chaplain, Social Worker, Medical Director, Volunteer Coordinator and Volunteers work together to accomplish the patients desires. This team effort helps address the patient’s complete needs; physical comfort, emotional and spiritual support. Treating the entire patient is very important. Then, after the patient passes the family has a great support system and grief counseling, and support groups available anytime there is a need. I have had many heart-to-heart talks with patients in addition to fun and silly times together. After every assignment I take time to reflect on the experience. I have always learned something from each patient. The patients and families have always thanked me and said how much my service and the Hospice services in general made a positive difference.
I encourage anyone interested in Hospice or in volunteering to call your local Hospice organization. If you have questions please contact me at christinalufkin1@yahoo.com. Christina is also available for interviews or guest speaking engagements. Christina Lufkin, Author “Live with Purpose:Die with Dignity” www.christinalufkin.weebly.com
Comments by Dr. Pullen: Over the years I have had nothing but positive experiences with hospice. When my Mom passed last spring Hospice was involved and they definitely made for a better experience all around. See my post, Saying Goodbye. Hospice has several major advantages from a flexibility and financial standpoint also for terminal patients. The Medicare reimbursement for Hospice is on a per-diem basis, and the Hospice team has a great deal of flexibility in choosing services to provide to patients, many of which would not be eligible for regular Medicare coverage.
You may also enjoy How We Fail and End of Life Care.
When Not to Do Screening Tests
An argument can be made that knowing when not to do screening for a disease or condition is as important as knowing when to do screening. The USPSTF makes recommendations to physicians and patients about what screening preventative services should be done in asymptomatic patients, and which should not be done routinely. The USPSTF is an evidence based decision making body. They carefully review the evidence and make recommendations for or against screening based solely on the available evidence which helps keep emotional and arbitrary recommendations from becoming the mandate. The recommendations are separated into 5 grades:
I thought it was timely to list a few of the screening services that the USPSTF recommends against, or finds insufficient evidence to make a recommendation for or against. This list is not intended to be comprehensive. See the USPSTF site for a complete list of their screening recommendations.
Cancer Screening Recommendations:
Heart and Vascular Disease Recommendations:
Other Recommendations:
These recommendations are for screening in asymptomatic persons. They are not recommendations against testing for a disease in the presence or symptoms or other factors where making a diagnosis may alter management decisions.
At first glance these recommendations may seem disappointing. Intuitively it seems like early diagnosis of cancer, glaucoma, coronary disease or chronic lung disease should lead to better outcomes. Unfortuntely the data does not lead to those conclusions. In some cases like prostate cancer screening the early diagnosis may lead to more morbidity and problems from testing and treatment than benefits of the earlier diagnosis provide. In other situations like screening for coronary disease screening the high incidence of false positive tests and the low prevalence of disease make screening impractical. In still other situations like COPD making the diagnosis does not lead to effective interventions that alter the course of the disease.
I am grateful that the USPSTF puts out these recommendations, and am hopeful that they will become more active again after political pressure of late seems to have slowed the pace of their production to a point where new recommendations are needed in important areas like PSA screening.
Tabex for Smoking Cessation: One More Tool for Smokers Trying to Quit
Tabex was reported in the prestigious New England Journal of Medicine to be more effective than placebo for help in quitting smoking. Sounds great until you read the actual numbers. Tabex was shown in a single fairly small study including only 740 patients that was conducted in Poland to have a 1 year success rate of 8.4% as compared to a 2.4% success rate with placebo. Admittedly this sounds like it is helpful in a small percentage of patients, but at best only about 1 in 12 patients using Tabex will be successful in quitting smoking.
Still having an inexpensive and over the counter product patients can use to try to get help in quitting smoking is exciting. Studies show that most smokers would like to quit smoking. Smoking rates have decreased significantly in the United States over the last couple of decades, but many patients in my practice just cannot seem to quit smoking. Chantix has been quite helpful for many patients, but significant Chantix side effects including cardiovascular concerns, vivid dreams, depression and even suicidality have been deterents to Chantix use. The high price of Chantix is also a major deterrent to widespread use. Bupropion, originally marketed as Zyban for smoking cessation, is sometimes helpful, but far from a panacea.
Tabex, chemical name cytosine, is structurally similar to nicotine, and functions as a nicotinic acetylcholine receptor agonist. It is an extract of the seeds of Golden Rain acacia (Cytisus laborinum) and Chantix is actually a derivative of cytosine and has been approved for smoking cessation in the U.S. since 2006. Tabex has b een used in Europe for nearly 40 years for smoking cessation and has been produced by a Bulgarian company Sopharma AD.
In the NEJM study Tabex was used on a 25 day tapering schedule, taking 6 tablets daily for the first 3 days, five tablets on days 4-12, and then tapering more quickly by taking 4 days on 4/day, 4 days on 3/day, until stopping on day 25 after 2 days of two tablets daily. At this dose toxicity seemed minimal, although the authors admit the study was too small to find uncommon adverse effects of Tabex. Cytisine has been documented to have serious side effects at much higher doses, so users should not take more than this regimen used in the NEJM study.
Tabex appears to be inexpensive, on E-bay I found vendors selling #100 1.5 mg tablets for $13.35 USD. This would amount to enough pills for a person to take the recommended 25 day regimen and have just a few pills left over. This compares to Chantix which costs about $179/ month at Drugstore.com.
This small NEJM study implies that this inexpensive, seemingly fairly safe drug, available without a prescription, is marginally effective for helping smokers quit the habit. I think it may be worth a try for smokers who have been unable to quit using nicotine replacement systems, cannot tolerate, cannot afford or have reasons not to use Chantix, and are motivated to quit. The long term adverse health effects of continuing to smoke seem to far outweigh the risks of essentially all of the smoking cessation aides for patients without specific contraindications to their use.
In European use for over 40 years there does not seem to have been much in the way of serious problems with Tabex use, and I anticipate the use of Tabex to increase significantly in the U.S since the NEJM article has given more validity to its use.
There is really little to no evidence that the other SSRI drugs like citalopram or sertraline help patients to quit smoking.
The abstract of the NEJM article is available here.
Crizotinib, recently approved by the FDA as Xalkori by Pfizer, is a great example of the concept of picking chemotherapy that is specific to an individual person’s cancer. As the physician whose wife is fighting ovarian cancer I have been following the progress in various cancer therapies with hope for major breakthroughs in cancer treatment. Personalized therapy for cancer is a work in progress, but crizotinib seems to be a good example of a drug where patients can be tested to see whether the drug is likely to work for their cancer.
The theory of testing cancer cells to see what drugs will be most effective is somewhat like the way we test the bacteria causing an infection to see what antibiotics work well to kill the specific strain of germ causing an individual patient’s infection. Bacteria are collected from the infection site and lab testing is done to see which antibiotics are most effective in killing those bacteria. Crizotinib is a chemotherapy agent that is an inhibitor of the enzyme anaplastic lymphoma kinase (ALK). Approved for use at the same time as crizotinib was a test called Vysis ALK Break Apart FISH Kit, made by Abbott molecular, that can be used to test the cancer cells to see if they express this specific enzyme. If a patient with non-small cell lung cancer has cancer cells that express this specific enzyme, then crizotinib may be useful in targeting the cancer cells in those patient. It would not likely be useful in patients where the cancer cells do not express the ALK enzyme.
Crizotinib is approved for treatment of advanced non-small cell lung cancer that expresses the ALK enzyme. The concept of choosing cancer treatments based specifically for an individual based on the characteristics of their cancer cells is very much in vogue and there is a good deal of hope for this type of therapy. An example of this type of therapy is the use of PARP inhibitors in breast and ovarian cancer patients who have the BRCA gene mutations. The theory in these BRCA 2 mutation positive patients is that since they lack the function of the BRCA gene that helps repair double stranded DNA breaks that inhibiting the PARP function that repairs single stranded DNA breaks will make cancer cells more susceptible to chemotherapy agents or the body’s own immune system. Although this is somewhat less targeted than the crizotimib approach it is theoretically somewhat patient specific therapy.
In breast cancer patients testing the cancer cells for estrogen receptor status, and targeting estrogen receptor positive tumors for anti-estrogen therapy with tamoxifen and other drugs has been standard therapy for years. New immunotherapy and antibody based therapies are also patient and tumor specific therapies. The ideal of using chemotherapy targeted specifically at an individual’s cancer cells rather that lumping all patients with a given type of cancer into the same regimens of treatment is unique and seems to hold much promise. Time will tell just how helpful crizotinib is for advanced non-small cell lung cancers that express the ALK gene, but this type of treatment where more specific therapy is targeted at an individual’s cancer cells is exciting and promising.
Although crizotinib is going to be targeted at a fairly small cohort of patients it is exciting to see the progress of personalized cancer therapy take one more step forward.
Aromatase Inhibitors are drugs that work within cells to inhibit the function of the enzyme aromatase, which facilitates the chemical change of androgens into estrogens. This process is called aromatization, and in postmenopausal women a large proportion of the estrogen available comes from the conversion of androgens into estrogens. In premenopausal women most of the estrogen comes directly from the ovaries, so inhibition of the aromatization of androgens is much less effective in controlling estrogen available to estrogen dependent cells.
The primary use of aromatase inhibitors is in the treatment of estrogen dependent cancers, primarily estrogen receptor positive breast cancers and ovarian cancers. Most oncologists first treat women with estrogen receptor positive breast cancers with estrogen receptor blocking medications like tamoxifen or reloxifene, but sometimes the aromatase inhibitors can be effective at slowing or stopping the growth of these tumors when tamoxifen has failed.
There are currently three aromatase inhibitor medications available in the United States. Two of these, anastrozole (Arimidex) and letrozole (Femara) are considered non-steroidal reversible competitive enzyme inhibitors, and exemestane (Aromasin) is an irreversible steroidal enzyme inhibitor that binds permanently with the aromatase enzyme and deactivates it irreversibly. Both letrozole and anastrozole are available in the U.S. as generic medications.
Not unexpectedly the primary side effects of the aromatase inhibitor medications mimic menopausal symptoms. Even though these are used primarily in post-menopausal women by reducing the small amounts of estrogen available they can lead to hot flashes, night sweats, vaginal dryness and these menopausal symptoms can be quite severe in some women. Other aromatase inhibitor side effects include bone and joint pain, an increased risk of osteoporosis, and headaches. Unlike the competitive estrogen receptor drugs tamoxifen and reloxifene the aromatase inhibitors are not felt to raise the risk of endometrial cancer or of endometrial sarcoma.
At this time the aromatase inhibitors do not have an indication for reduction of risk of developing breast cancer like tamoxifen and reloxifene have. Research is felt to be needed to see if this potential use of the aromatase inhibitors is going to be effective and whether it is worth the potential risks and side effects these the aromatase inhibitors can cause. One study, the MAP3 study did seem to show a reduction in the incidence of invasive breast cancer in women on exemestane vs. placebo.
All of these drugs are used orally as a once daily dose, and all have similar indications. All are used both as early postmenopausal therapy in estrogen receptor positive postmenopausal women with breast cancer, usually after more aggressive chemotherapy, or as adjuvant therapy after recurrence of breast cancer while on an estrogen receptor blocker.
Generic versions of both letrozole and anastrozole are available in the US as their patents have expired, but online price comparison is not easily available.
There are other potential uses of the aromatase inhibitor medications that do not have FDA approval in the U.S. One of these is for treatment of gynecomastia. These drugs are sometimes used on the black market by athletes using anabolic steroids to prevent the aromatization of the androgens into estrogens which can lead to Gynecomastia. Another use of the aromatase inhibitors is in treatment of benign estrogen sensitive tumors called leiomyomata, or more commonly fibroid tumors. Fibroids are the most common reason for hysterectomy in the U.S. and at least one study showed significant shrinking of the size of fibroid tumors with a 90 day course of anastrazole. An FDA approved treatment of fibroid tumors is embolization of the arterial blood supply of the fibroids. This can be done with coils placed in the arteries by arterial catheterization at angiography, or other similar techniques.
It will be interesting to see if use of the aromatase inhibitors for estrogen sensitive conditions other than breast and ovarian cancer becomes more widespread in future years. Their difficult side effects of the aromatase inhibitors makes this less likely than if they were easy to tolerate.
When No Immediate Treatment is The Best Option for Prostate Cancer
“Don’t Just Do Something, Stand There!” When No Immediate Treatment is The Best Option for Prostate Cancer
by Patrick Maguire, MD
As we near the end of Prostate Cancer Awareness Month this September, hopefully many of us have learned a thing or two that we didn’t know about the disease in August. Just last week, a major study of predictors of sexual function after prostate cancer treatment was published in the prestigious Journal of the American Medical Association (JAMA). I found some important info in the paper and recommend it highly to men who are considering their options for treatment. The link for the full document is: http://jama.ama-assn.org/content/306/11/1205.full.pdf. An in-depth discussion of the topic can be found at on my blog The Cancer MD. As opposed to various treatment choices, one option for men after a prostate cancer diagnosis that we don’t hear too much about in theU.S. is active surveillance.
Many terms have been used to describe what is now most often called active surveillance. These include: watchful waiting, close observation, and expectant management, among others. Given the right circumstances, the option of avoiding prostate cancer treatment altogether is often best. Which men are candidates for watchful waiting after their diagnosis?
To be sure, prostate cancer is a spectrum of disease that can range from indolent to extremely aggressive. Men with low-risk prostate cancer may be good candidates for no immediate treatment. These cancers can’t be felt or are only felt in part of one side (lobe) of the prostate, produce a low level of prostate specific antigen (PSA) in the blood, and appear not too aggressive under the microscope (Gleason score of <7). Among this group, younger, healthier men are usually the best served by treatment.
Men with low-risk disease who are either older or in poor overall condition should strongly consider expectant management. In general, it takes more than a decade for early prostate cancer to spread to other sites in the body (metastasize) and ultimately kill a man. Therefore, men who have a life expectancy less than 10-15 years should think long and hard about the option of no treatment. In medical school, we docs agree to abide by the Hippocratic Oath, a major principal of which is “primum non nocere” (do no harm). We don’t want to put a man at risk for possible side effects of treatment, unless we have reason to believe that the treatment has a good chance to improve survival or quality of life.
So, if you or your loved one has been diagnosed with prostate cancer that’s found very early, ask your urologist or radiation oncologist whether active surveillance or watchful waiting is a reasonable option. Sometimes, though it may feel strange, you might have to tell him or her, “Doc, don’t just do something. Stand there!?
Dr. Maguire regularly posts on TheCancerMD.com and is the author of a book that I have enjoyed reading that helps laypersons understand the language, facts and treatment options for the most common cancers. When Cancer Hits Home: Cancer Treatment and Prevention Options for Breast, Colon, Lung, Prostate & Other Common Types.