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Futile Care: A Sad Case Of Wasted Resources

A 90-year old man with a pancreatic mass, almost definitely pancreatic cancer, was admitted to a hospital.

Surgeon Jeffrey Parks does the initial surgery consult on this terminal case, and recommends hospice care.

The next evening, he’s shocked by the “astounding amount of medicine [that] had been practiced” during the day:

Consults had gone out to GI, oncology, and nephrology. The GI guy had ordered an MRCP and, based on some mild distal narrowing of the common bile duct, had scheduled the patient for a possible ERCP in the morning. A stat CT guided biopsy of the liver lesions had also been done. The oncologist had written a long note about palliative chemotherapy options and indicated he would contact the son about starting as soon as possible. The nephrologist had sent off a barrage of blood and urinary tests.

It’s often said that we spend the most money in the world on futile care, often with little benefit to the patient. The preceding account was that phenomenon in action, replicated thousands of times on a daily basis.

A microcosm of what’s wrong with American medicine indeed.

*This blog post was originally published at KevinMD.com*

Patrick Swayze Diagnosed With Pancreas Cancer

Patrick Swayze, the popular actor perhaps known best for his role in the 1987 hit movie “Dirty Dancing,” reportedly has pancreas cancer (commonly called pancreatic cancer). Pancreas cancer is among the more deadly forms of cancer. I asked Revolution Health cancer expert Heinz-Josef Lenz, M.D., professor of medicine and professor of preventive medicine in the Division of Medical Oncology at the Keck School of Medicine at the University of Southern California, to explain pancreas cancer.

Dr. Val: Why is pancreas cancer so much more deadly (i.e. less treatable) than many other forms of cancer?

Dr. Lenz: Unfortunately we don’t have very effective drugs for pancreas cancer, which makes it one of the deadliest cancers of all. The median survival is about 8 months with metastatic disease. Even when the tumor is successfully removed there is a very high risk for tumor recurrence. We need more funding to better understand the risk for pancreas cancer and identify and develop more effective therapies.

Dr. Val: Can you describe the typical course of metastatic pancreas cancer?

Dr. Lenz: Unfortunately, the 5 year survival rate for pancreas cancer is only 15 to 20%. The average survival after diagnosis is 12 to 19 months. The best predictor of long term survival is if the tumor is found and removed before it reaches 3 cm in size. Patients with metastatic pancreas cancer are usually treated with a combination chemotherapy consisting of gemcitabine, tarceva, xeloda or oxaliplatin. However the response rates are (despite using aggressive combination therapies) low. Large clinical trials recently did not show any benefit from erbitux or avastin, again demonstrating that pancreas cancer therapy is a difficult clinical challenge.

Dr. Val: Are certain populations at higher risk than others for pancreas cancer?

Dr. Lenz: Age is the most important risk factor for this cancer. It is most common in individuals over age 50 and increases in frequency with age. Black men and women are slightly more likely to get pancreas cancer (though the reasons for this are unclear), and men are slightly more likely than women to get the cancer. Other risk factors are smoking, diabetes, and obesity.

Dr. Val: If you suspect that someone is “high risk” for pancreas cancer, what tests should he/she have?

Dr. Lenz:  Patients with a genetic predisposition for breast cancer known as BRCA are also at higher risk for pancreas cancer. There is also a familial form of pancreas cancer. These high risk families are being followed up with specific screening plans. However there is not a reliable test for pancreas cancer. Imaging with CT or MRI can miss pancreas cancer and there is no reliable blood marker. The most common used is CA 19-9, which can be used for monitoring and diagnosis but is not elevated in all patients.

Dr. Val: What if the cancer is caught very early? Does that increase likelihood of survival?

Dr. Lenz: Absolutely. The best chance of survival is when the cancer is limited to the pancreas, and is surgically removed before it reaches a size of 3 centimeters. There are certainly people who have been cured this way, but unfortunately it’s very rare to catch the cancer at such an early stage since it usually has no symptoms until it’s quite advanced.

***

There is a wonderful advocacy group for those whose lives are touched by pancreas cancer: PanCAN. One of PanCAN’s founders, Paula Kim, is a friend of mine and was inspired to create the organization after her dad was diagnosed with pancreas cancer in 1999. At that time there was very little advocacy for this deadly disease. PanCAN helps people with pancreas cancer find help and support.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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