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Review of Wrong Medicine (7/10/13 issue)

I appreciated reading Dr. Robert Young's review of Wrong Medicine in the July 10 issue. Although the last two paragraphs of the review do provide some balance to the premise provided by this book, I worry that some readers may not have read that far.

 

Many of us who have been in oncology since it first became a sub-specialty of Internal Medicine have misgivings about the current rising tide of a very prevalent form of palliative care that focuses on identifying patients for whom care is deemed futile. Many hospitals are looking askance at patients with advanced cancer. Some are sent home without any treatment altogether. Medical schools have adopted the palliative care credo of avoiding futile therapies as a standard of their curricula.

 

Of course, this does not apply only to cancer patients. Patients with multiple sclerosis, those transferred from nursing homes, elderly patients with congestive heart failure or COPD, others who are demented or over 90 years old have been specifically identified as targets for supportive treatment only, because someone has considered their treatment as futile.

 

Even if you agree that this is proper, that we have to begin choosing which patients we will treat and whom we will leave to the mix of formal and informal approaches referred to as supportive care, shouldn't we have a more vigorous debate about the matter? As I look through our own oncology publications I see a sea of "me too" articles on how to adopt palliative care as our own standards, implementing it despite the significant misgivings among our fellow physicians, implementing it even against the wishes of patients and their families. Where is the thoughtful, in depth debate that can provide some balance to the matter?

 

What is the actual cost of taking care of patients with advanced cancer? Perhaps some individuals would want to insure themselves to cover these costs? Perhaps the costs are not as overwhelming as are implied by articles? What is the cost of the growing palliative staffs that hospitals are accumulating? How can we reassure hospitals that they can afford to take care of cancer patients with advanced disease?

 

We need hard honest facts on the size of the problem, not loose predictions of what will happen in 20 years. We also need to explore the various options that may solve financial concerns. Furthermore, let me whisper, we need to control drug costs. How can we do the latter without stifling drug research?

 

In general we have made progress in treating cancer in small steps. The FDA approves drugs on the basis of 2.5 months or less extension of overall survival. Why all the trumpeting of progress when the other side says it's just not worth it? Yet, afraid to speak out, we publish our most recent revised guidance on palliative care?

 

This is a hot topic. If those who expound avoidance of futile care are correct, so be it. However, make no mistake, if their focus is misleading us to taking less that optimal care of our neighbors and friends with cancer, then we will and should be held responsible for our silence.

 

YASHAR HIRSHAUT, MD, FACP

 

Reply from OT Editorial Board Chair Robert C. Young, MD:

Thanks for reiterating the point made in the last two paragraphs of my review of Wrong Medicine. I suspect that very few, if any, of the 10,000 patients on life support described in the book are oncology patients with no remaining therapeutic options of benefit. Oncologists generally know what constitutes futile care in our specialty. There is little a reviewer can do if the reader decides to draw conclusions based upon reading only part of the review. Hopefully, others, as you did, will read to the end and appreciate that a balance has to be achieved.

 

Emil Frei III, MD (OT, 6/10/13)

I am heartbroken to have learned of Dr. Emil Frei's death, and I extend my condolences to those of you who respected and loved him so deeply.

 

In 1960, my brother Willie was diagnosed with ALL. His local pediatrician had heard of Dr. Frei's research and clinical protocols at NIH in Bethesda, and referred Willie there for treatment. Along with Dr. Freireich, and against the prevailing sentiment that childhood leukemia was incurable, Dr. Frei worked tirelessly to help Willie and dozens of other brave little warriors similarly stricken.

 

Although Willie ultimately succumbed to the terrible ravages of ALL, it was through Dr. Frei's dedication to what I call the Great Mission that a virtual cure for the horrible invader was found soon thereafter. To say that I and my family loved Dr. Frei would be a monumental understatement.

 

I have written a book in Willie's honor which follows his courageous, 21-one month battle. The memoir is currently in edit, and I shall now dedicate it to the amazing career and unflinching devotion of Dr. Emil Frei, III.

 

I want all of Dr. Frei's colleagues and friends, and surviving family members, to know of the love and respect that Willie's family has for so many long decades held for our dearest Dr. Frei.

 

JOHN L. BOWERS, III

 

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