How We Do Harm (9 page)

Installing that elevator might have been the smartest thing I did when I was designing the Grady cancer center.
This was a massive renovation of the hospital’s ninth and tenth floors, which had been abandoned when the hospital ran out of money during the renovation for the Olympics.
Several shafts were left without elevators when the renovation was stopped.
I took one of those shafts and bought an elevator.
That elevator is dedicated to the cancer center, an express run from the ground floor.

Martin would later tell me that he viewed the elevator as a space vehicle that transported him out of the dreary surroundings of the county hospital to the cancer center, which looked more like a doctor’s office in the suburbs.

As the door opens, Martin and Rae enter a room that has bright prints on the walls and clean carpets on the floors.
First, Martin has to make arrangements for payment.
Grady will bill him for the copays, but will expect him to pay only what he can afford.
The hospital writes off the rest.
The financial adviser explains that all outpatient prescription drugs will be charged at $2 per prescription.
She notes that $2 at Grady even buys drugs that cost $1,000 at regular pharmacies.

Martin and Rae are ushered into an exam room.
After a half hour that seems like an eternity, Camille Gray walks in.
She is a hematology-oncology fellow.
“What is a fellow?”
Rae asks.
Camille explains that she is a physician who is training to become an oncologist, then asks how she can help.
Rae starts to ask why they are seeing a student doctor, but Martin stops her and starts explaining his story to Camille.
A student doctor is better than no doctor.

As Martin talks, Camille reads through his records and examines his CT scans.
She asks a few questions about the chemo that he has received, verifying the schedule, trying to verify the drugs.
Martin doesn’t know the names of all the meds, but he does remember 5-FU.

Camille examines him, to make sure the physical findings are consistent with the history.
He has a little mild mucositis, rawness in the mouth, a result of chemotherapy.
His belly scar is healing well.
No lymph nodes are palpable in the neck and upper clavicle area.
The liver and spleen are not palpable, the belly is soft, and there are no masses.
His labs drawn a week earlier are indicative of chemotherapy a few days before.

Our fellows are taught to verify everything in a patient’s story for consistency with the record and the exam.
Occasionally, we get people who tell compelling stories that fail to check out.
They come to us because they want attention or, worse, in hopes of scoring some “good drugs,” narcotics for recreational use or street commerce.

Around the corner from Grady, a single Vicodin tablet goes for $20.

*

CAMILLE
leaves the room and prepares to “present the case.”
Presenting the case is a century-old medical tradition.
Other fellows and students, one other attending who is not busy, and some nurses, nurse’s aides, a social worker, and some patient navigators gather in the multipurpose room in the former white section of the tenth floor to hear Camille discuss Martin’s case.

All young physicians and even some of us middle-aged ones are called on to present.
The order of information in the presentation is the same today as it was more than a century ago.
The only change is the modern addition of results of lab tests and imaging studies.

Camille addresses the presentation to me, the attending in charge of the clinic that day: “Mr.
Schmidt is a fifty-eight-year-old white male with a two-month history of Stage IIIB adenocarcinoma of the colon.
He was diagnosed initially at Piedmont Hospital, after presenting with loss of consciousness due to anemia.
He was found to have a colon cancer in the transverse colon.”

I am of the school that believes that medical education need not be boring.
“Let me guess.
Mr.
Schmidt’s wallet biopsy turned up negative,” I throw in.

Camille smiles.
Of course it’s the wallet biopsy, the means test revealing inability to pay.
Can there be any other explanation for a guy who gets initial care at a rich-people hospital to turn up here at Grady?

She proceeds with clinical details: “CT of the liver is negative.
It was resected in a good operation, and he recovered well.
He began chemotherapy with bolus 5-FU and leucovorin and now comes to Grady because he cannot afford the chemotherapy.”

“What do 5-FU and Otis Brawley have in-common?”
I ask.

“Hmm…” Camille rolls her eyes.
“You are also a thymidylate synthase inhibitor?”

Good, she knows the mechanism of action of 5-FU.
Camille tilts her head to the right and looks at me with expectation of some absurdity.

“Age,” I say.
“Five-FU was first used in chemotherapy in 1959; Otis Brawley was born in 1959.
We’ve been doing the same bullshit for fifty years.”

I mean this, at least half of it: 5-FU is a marginally effective drug.
For a long time, we didn’t even know whether it increased the patients’ survival.
Yet, for a couple of generations, gastrointestinal oncologists prescribed it to desperate patients.
Since there was nothing else around, it was the standard of care.
Leucovorin is a folinic acid.
It’s believed to work synergistically with 5-FU.

Camille smiles at the joke and proceeds to a suggested treatment plan.
“As Dr.
Brawley noted, 5-FU/leucovorin is an obsolete regimen for a healthy man with the status postsurgery for Stage III disease.”

I start out at the presentation knowing nothing about the case, like a priest sitting in a confessional.
Camille’s presentation has intrigued me, and I begin thumbing through the papers in front of me.
I glance at the patient data and the surgery report.
“Does this gentleman stand to benefit from chemotherapy?”
I ask, continuing to look through the loose pages in front of me.

Of course Camille knows the answer, but I want be sure that she is able to recite these facts with poise at a patient’s bedside.

“The literature indicates that he does,” Camille says—correctly.

A patient with Stage III colon cancer has a 50 percent to 60 percent chance of its recurring, she continues.
She cites randomized trials done in the 1980s that 5-FU–based therapy could lower the chance of death by about 30 percent.
This reduction in relative risk translated into a 10 percent boost in five-year survival.

“Is there any controversy over this?”
I ask.

“No,” says Camille, citing a 1990 consensus conference that recommended that all Stage III patients whose disease had been fully removed surgically and who are medically fit to withstand chemotherapy should be treated with 5-FU.

“So, should we also treat this gentleman with 5-FU?”
I throw in.
It’s another trick question.

“No,” says Camille.
“Five-FU as a single agent or 5-FU with a modulator like leucovorin would have been appropriate in 1990, but not today.
I believe we should consider treating this gentleman with FOLFOX.”

Correct.
FOLFOX is a combination regimen that includes the newer drug oxaliplatin in addition to 5-FU/leucovorin.
Oxali is a platinum drug that has been used extensively in colorectal cancer.
Platinum drugs are made of hydrogen and carbon molecules around one molecule of platinum.
The first platinum drug was Cis-Platinum, which is commonly used to treat lung cancer and is part of the curative regimen for testicular cancer.
Camille quotes a trial called the Multicenter International Study of Oxaliplatin, 5-Fluorouracil, and Leucovorin in the Adjuvant Treatment of Colon Cancer as evidence to support her assertion.
This trial—its name is abbreviated as MOSAIC—redefined the way we treat colon cancer.

MOSAIC showed a five-year disease-free survival rate of 73 percent in the FOLFOX arm and 67 percent in the 5-FU-leucovorin arm.
This result was statistically significant, meaning that it was unlikely to be a fluke—FOLFOX was a better treatment.

The increased survival rate with FOLFOX comes at a cost of peripheral neuropathy, which in 12 percent of cases becomes severe.
This is no small problem.
A patient receiving this drug may have difficulty buttoning his or her clothes.
But the improvement in outcomes is significant enough to become the standard of care.

“When would 5-FU/leucovorin only—without oxali—be appropriate?”
I ask, looking for the name of the guy who treated Martin.

“I would consider it for a little old lady with Stage III colon cancer, who was otherwise healthy and appeared to have a less than ten-year life expectancy,” Camille says.

The oxaliplatin in FOLFOX might be too harsh for an older patient, but a fifty-eight-year-old otherwise healthy guy can tolerate it, and studies say his risk of relapse would go down a bit.
Camille is right.
Five-year survival with FOLFOX is better than 65 percent.
Martin’s chances of survival are far worse—and not quantifiable—with lousy treatment.
Any patient deserves every effort to do the treatment right.

Camille continues, “Even if I were giving 5-FU/leucovorin alone, I would not give bolus, which is what this patient was getting.
I would give it by continuous infusion.”

“Why?”
I ask.

Camille talks about the clinical studies that have shown that infusional 5-FU has different side effects from a bolus.
A bolus is the fast way to give 5-FU, and that’s not a good thing.
Literature shows that slow methods of administration—an infusion pump that dispenses the drug over twenty-four hours or so—is not as toxic.

Before newer drugs came along, GI oncologists busied themselves trying to define the best way to give 5-FU.
(This was kind of sad.
There were no other drugs, nothing else to study.)
The regimen Wilson was giving Martin, called the Mayo Clinic Regimen, had been surpassed as the preferred regimen by the Roswell Park Regimen, Camille says.
It’s less toxic.
It’s a once-weekly 5-FU/leucovorin given for four eight-week courses.
She then says that she likes another method, the de Gramont Regimen, even more.
In this regimen, 5-FU is given by long-term continuous infusion.

“Does everyone here remember
Forrest Gump
?”
I say.
I can’t help it.
It’s one of my favorite movies, and many things in life—at least my life—remind me of it.
“I think of what Forrest Gump says of the various ways to serve shrimp,” I continue through the giggles.
“You can give 5-FU by IV bolus, you can give it by twenty-four-hour infusion, you can give it by five-day infusion, you can give it by seven-day infusion, you can give it with leucovorin, you can give it in oral form, which is toxic and expensive as shit.
It just goes on and on.
I mean, really, why would anyone give 5-FU/leucovorin to a patient who can tolerate something better?
The thought of it pisses me off.”

“Beats me,” says Camille.
“Maybe the physician in question hasn’t kept up with the literature.”

“He’d have to be brain-dead to have missed the literature,” I offer.
“What’s his name anyway?”
I had seen the name by now, but it’s important to let the name come out.
Bad docs tend to resurface, and it’s important to be prepared.

“That would be Dr.
Cameron Wilson,” she says, and I decide not to press further.
Wilson was, in effect, depriving Martin of a chance of a better outcome, perhaps even a cure.
I wanted to look at the charts to see for myself what might have been going through Wilson’s mind.

After everyone leaves, I stay on, continuing to thumb through the chart, interrogating it, trying to grasp its deeper meaning.
What I see frightens me.

If you are poor, black, and uninsured like Edna, you get no care until it’s too late.
This is no surprise to anyone.
But if you are rich, white, and insured, you face another deadly menace, a Dr.
Wilson, a socially prominent physician who is just plain bad.
As a patient, you would see his social prominence—he might even belong to your country club—but you would have no way to see his inadequacy as a physician.

Even the surgeon who did a competent resection recommended this doctor to Martin.
If you can’t trust a recommendation of your surgeon, what can you trust?

Reviewing the chart, I am unable to understand why Wilson agreed to take on Martin.
Colon cancer isn’t even his area of specialization.
Oncologists, like all doctors, get better at something if they do it all the time.
Wilson did a lot of adjuvant therapy for breast cancer, and with the exception of his overuse of supportive-care drugs, he did it reasonably well.
For him, adjuvant chemo for breast cancer was relatively easy, like following a recipe from a cookbook.
You only have to be an adequate doctor to do this well.
Providing adjuvant therapy for breast cancer is a great place to be mediocre: no clinical judgments need be made, and the money is good.

Did Wilson want to diversify?
Were his sales lagging?
Did he think Martin’s insurance was too good to pass up?
I don’t know.
What I do know is that a doctor like him would have been weeded out at Grady.
At Grady, we have standards for treatment of commonly seen diseases.
These standards take into account the national and international treatment guidelines and receive input from Emory’s disease-specific experts.
The doctors at Emory who only treat GI cancer also rotate through Grady and are charged with verifying that our standard of care for colon cancer is appropriate.

We look over each other’s shoulder to see how we are treating patients.
This is an added degree of quality control that you do not see in private practice and sometimes not even in an academic practice.
The system at Grady does allow for varying from the standard of care, but we have to discuss it with peers and with our patients.
We have to have a valid reason for deviation.
This means solid medical literature, not the pleadings of a drug rep, even if she offers a free meal and tickets to the Falcons-Saints game.

Camille had only twenty-five minutes to make her presentation, and there was a lot to talk about.
I deliberately focused on the standard of care for Martin’s disease.
Now, as I stare at the papers, I look at Wilson’s use of a drug that builds red blood cells and another drug that builds white blood cells.
These are expensive drugs that the patient likely didn’t need.
I see no indication that Martin was anemic or that his white blood cells were down low enough to justify a pharmacological intervention.