Sunday, October 25, 2009

The Hopkins Oncologist

As mentioned earlier, on Thursday we traveled to the cancer center at Johns Hopkins in Baltimore. From Avondale, by the time you struggle your way into town and into a space in the cramped parking garage underneath the Weinberg Building, it’s a good hour and forty minutes. When we emerged onto the main floor of the center, at around 2:15 P.M., the place was a beehive of activity. It’s obvious that a lot of cancer is being treated here. I was told to arrive an hour before my 3:30 appointment, so that I would have plenty of time for the first-time registration process. That accomplished, we were directed to a reception area in which a large number of people were awaiting their appointments. I feared a long wait; we were early, and my experience has been that, for a 3:30 appointment with an oncologist, you never get called as early as 3:30.

Image my surprise, then, when I was called for at 3:10 P.M. We spent the next 90 minutes with the person that I will henceforth identify as “the Hopkins oncologist”, to distinguish him from “the Christiana oncologist” (or just “the oncologist”).

The first thing that became apparent was that there had been some miscommunication between the staffs of these two oncologists. Although I had been told earlier that the Hopkins oncologist had obtained from the Christiana oncologist everything necessary for an initial consultation on my case, that was in fact not quite true; some, but not all, of the necessary material had made the jump in time. It was therefore necessary for me to recite once again the short version of the story of my ordeal up until now. Then, after asking me a series of clarifying questions, the Hopkins oncologist launched into his pitch.

The Hopkins oncologist’s team does almost 300 stem cell transplants each year. It is just about as much a routine as such a complex process can be. But every case follows its own course, since every patient reacts uniquely to the chemotherapy drugs, encounters different difficulties in the recovery phase, and so on. But then he said something that I was really not expecting:

“We really don’t have good evidence that the high-dose chemotherapy provides any additional benefit”.


He explained himself by showing me graphical representations of the survival data collected as a part of the original long-range studies comparing high-dose with low-dose chemotherapy treatments for hematological cancers. These showed a clear advantage for high-dose chemotherapy. “But these studies were done in the early 1990’s, with the chemotherapy drugs in use twenty years ago. The drugs we use now are completely different – much better. There is no way to know if high-dose chemotherapy would still compare so favorably with the low-dose. No one is going to repeat these studies anytime soon. They are very expensive to do. But this is the only evidence we have, so we have no choice but to continue to recommend stem cell transplant for patients like you.”

And by extension, I have no choice but to undergo stem cell transplant, unless I am happy with the idea of being a one-man control group. So much for the facile assurances that we would save many billions of dollars, if only physicians could be prevailed upon to practice “evidence-based medicine”, thus eliminating “unnecessary” treatments.

If I decide to go ahead with stem cell transplant at Hopkins, I would be assigned a case coordinator, who would handle all of the logistics leading up to the beginning of treatment. It would take about a month to get everything lined up (getting insurance approvals, making short-term housing arrangements, scheduling lab and clinic times, etc.); meanwhile, I would continue the low-dose chemotherapy regimen. When asked whether I should go ahead with the outpatient physical therapy, which would of course have to be interrupted for the transplant, the Hopkins oncologist answered in the affirmative: “You want to be as strong as possible for this”. And as fat as possible; this is one of those rare cases in which fat people do better than thin people.

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