Tuesday, May 17, 2016

My latest news

Back on April 22, my wife and I went to Sloan-Kettering for my latest CT scan. We got the results a few days later (and my apologies to any readers who’ve been waiting for an update) – and they were good. The tumors have continued to shrink, and by as much as another third since the scan in February.

This, of course, is really good news. When I began chemotherapy, the doctors at Sloan-Kettering told us that one-third of patients see a reduction in their tumors’ size as a result of this treatment; for another third, the tumors don’t contract but also don’t continue to expand; and for the final third, the tumors keep expanding despite the treatment. I’ve now had two stretches of this treatment, from December through January, and from February through April, and in both stretches I’ve been in the first, most fortunate third of patients. I am truly grateful.

There are evidently people who continue on the chemotherapy I’m currently on (the so-called “gold standard” combination of two drugs, gemcitabine and cisplatin) indefinitely. The problem, however, is that for many patients any one treatment eventually loses its efficacy – apparently because the cancer, already in some important degree the result of genetic mutations, tends to continue mutating and to eventually hit on a mutation that gives it resistance to whatever treatment has so far been used against it. Or, in Gareth Cook’s words in this past weekend’s Sunday New York Times Magazine, “Darwin’s survival of the fittest governs inside a tumor, selecting for a crueler version of the disease.”

So this raises the question of what other treatments can be brought to bear, and when they should be employed. This is a very promising moment in cancer treatment – there are all kinds of new drugs and new approaches. Unfortunately that doesn’t make the task of deciding what to try easier! Among the most promising possibilities are immunotherapy trials – for example with a drug called Keytruda, recently used as part of a very successful course of treatment for Jimmy Carter’s brain cancer. Another intriguing one is a drug not yet in clinical trials, called 3-bromopyruvate, which another article in the Sunday Magazine, by Sam Apple, reports has “wipe[d] out advanced liver cancer” in rats and rabbits.

The most promising trial, however, may be a more conventional one, in which a pump is implanted in the abdomen and then connected via a tube to the artery leading to the liver; once this is in place, chemotherapy can be delivered straight to the liver. My current chemotherapy is “systemic,” meaning it goes through my blood stream to my whole body; it’s good to have systemic treatment, to ward off any spread of the tumors from the liver elsewhere, but at the same time treatment of the whole body probably has less intense impact on the liver by itself than treatment targeted right to the liver. One of the best features of this clinical trial, moreover, is that the systemic treatment can continue along with the directly-targeted treatment.


So that’s where matters stand right now: we’re assessing what treatment option to take up. No one says that we have to decide overnight – but obviously we do want to decide as soon as we feasibly can. A tricky problem, but one that I’m fortunate to have.  

Saturday, April 23, 2016

Cancer hospital advertising, continued

Here’s the website logo of another institution, whose full name I won't include (for my first comment on cancer hospital ads, click here):

            [The first part of the institution's name]
            Cancer Center

            Making Cancer History

As you can see, the word “Cancer” is struck out; but actually on the website it’s struck out in red, and the red line through the word “cancer” ends with a brief downward curve, as if it had been added by hand, and with a flourish. The implication is that this institution has struck cancer out, which, sadly, is not true.

It may be true that this institution is “making cancer history” in one sense of those words: that in the annals of the treatment of cancer, what this institution is doing stands out. But “making cancer history” has a second meaning, which readers must also have been meant to think of: that this institution is making cancer a thing of the past. Again, sadly, that is not true.

But there’s another issue, one not particular to any institution but probably common to all institutional advertising. The phrase “making cancer history” doesn’t convey much information, but it does seek to generate – and rather cleverly, I must say – a positive feeling about the institution. There’s nothing wrong with generating positive feelings; in fact, I’m inclined to agree with scholars who maintain that all reasoning is laden with feelings.

But reasoning isn’t only about feelings, and here the positive feeling doesn’t come from any actual experience with the institution but just from the wit and attention-getting design of the institution’s logo. I don’t really think that a website logo can sway people’s judgment, but branding is an important part of marketing, and if marketers embrace it that’s because it is effective.

So, really, the question is: is it possible for a cancer hospital’s brand to be too clever?

Friday, April 22, 2016

The latest in hospital construction

Today Teresa and I went to Montvale, New Jersey for my latest CT scan. We’re hoping for good results, naturally, but meanwhile I have to post Teresa’s photograph of the Memorial Sloan-Kettering facility in Montvale:






It’s a trailer!

But it was fine – carefully set up inside and professionally staffed. And it will soon be replaced with something much more conventional, as MSK takes over a large building on the same site, now evidently being fitted out to be a large medical complex.

Aside from giving us the treat of getting a high-powered medical test in a trailer, what this facility reflects is that MSK is moving into New Jersey in a big way. They already have a building quite a ways from New York, in Basking Ridge. Now they’re opening this Montvale office (in north Jersey), and another in Middletown (in central Jersey). These facilities will certainly make life easier for New Jersey patients, including us.

I assume, however, that the reason for these new branch offices isn’t just our convenience, but also MSK’s business plan. MSK must want to ensure or expand its position in the New Jersey cancer treatment market. And that’s part of a health care reality: as the advertisement for another cancer facility that I saw at the Montclair train station reflects, in today’s world cancer treatment institutions, even nonprofits, are competing with each other for patients. This competition is like the competition among colleges for students, and one of its features is the effort to make the customers, here cancer patients, comfortable.

I’m not sure what to think about the overall functioning of this segment of the health care market – but I do appreciate having a nearby office for my CT scan. Even if it’s in a trailer.


Sunday, April 17, 2016

How not to advertise a cancer hospital

Treating cancer is a business. Even not-for-profits want patients, and the fees and reputation that come with them. So hospitals advertise their services, and in particular their cancer services. I’ve seen ads for Weill Cornell and Memorial Sloan Kettering, among other places.

These can’t be the easiest ads to create, since the undeniable truth is that some cancers are harder to treat than others, and so the only way a cancer center could have a record of complete or near-complete success would be to avoid all the difficult cancers. Medical institutions also have to wrestle with ratings systems that may be no more reliable than those that have caused so much distress among law schools. Many people in need of cancer treatment might, in the absence of ads, rely on even vaguer reputations, or on no information at all. Nevertheless, there should be limits, whether they’re created by law or just by good judgment.

So consider this ad (from an institution I won’t name), on display at the train station near my house. The most prominent text, other than the institution’s name, reads as follows (I haven’t reproduced the typography exactly, but this will give you an idea of its appearance):

            CANCER IS SMART.
            BUT WE’RE SMARTER.

              WINNING
            IS EVERYTHING.

            We’re outsmarting cancer with science.

Now, really. We haven’t yet outsmarted cancer with science, though we’ve made headway. It’s true that the text doesn’t quite say we’ve already outsmarted cancer, just that “[w]e’re outsmarting it,” but the distinction is hardly emphasized. After all, the institution says that “we’re smarter” than cancer. And the line “WINNING IS EVERYTHING” certainly implies that the institution is offering this “everything.” That can’t be true, at least for many patients, who will sooner or later lose their fight with cancer. That’s aside from the question of what “winning” means, and of whether “winning” that consisted of beating back a cancer at the cost of the patient’s quality of life would really be “everything.”

That’s all bad enough. But the final straw is the racial politics of the accompanying illustration. This picture features, from left to right, a male South Asian doctor whose name is visible on his white coat; a female Asian doctor whose name is, similarly, visible on her white coat; and a bearded black man, dressed in a short-sleeved blue shirt with no name visible, who is presumably an assistant of some sort. These pictures are planned, and these individuals chosen. It’s true that all three are people of color, but even so this picture seems to embody a pretty stereotypical image of medical expertise.

It may be good to have institutional advertising for cancer treatment. But not like this. 

Saturday, April 9, 2016

Cancer and paternalism: a postscript

My post a couple of weeks ago on “Cancer and paternalism” discussed what Paul Kalanithi’s doctor said to him about survival rates, and why, and two readers of that post asked, essentially, “what about you” – what have my doctor and I said to each other?

Kalanithi asked to talk with his doctor about survival data; I’ve never asked that question. What I’ve asked is whether I could make a commitment to carry out a work project. The first time I asked that question, in December 2015, the doctors declined to answer, and in hindsight I believe that was because at that point they were worried that I might be in a perilous decline. By late January 2016, however, it was clear that I had pulled out of that decline; even while in the midst of chemotherapy, I was visibly healthier than I had been at the start of my treatment. My oncologist concluded, even before the February CT scan, that I was not only tolerating the chemotherapy well but actually beating back the cancer, and told me that I could commit to the two-year project I’m now at work on, writing Arthur Chaskalson’s biography.

Why haven’t I asked for a prognosis? Because I haven’t felt it would help me fight my illness or to live my life. I knew from very early on that the statistics for liver cancer are not good; what I’ve aimed for, always, is to wind up on the right side of those statistics. Saying you want to be on the “right side of” something is a figure of speech, but actually it’s the right phrase statistically too, as Stephen Jay Gould pointed out years ago. A graph of length of survival, beginning on the left with zero and ending at whatever the final endpoint is, will naturally stretch out towards the right – unless everyone dies at once, which fortunately is not at all the case with cholangiocarcinoma – and I want to be way out on the right side of this curve. The doctors can’t know if that will happen or not, and it seems to me that my mental focus should always be on seeking to live, rather than on worrying about not succeeding. I’m also certain that seeking to live is not just about surviving but about living each day happily and fully, and I want to focus my energy on doing that.


Homer tells the story of Ulysses having himself bound to a mast, from which his sailors are forbidden to release him, so that he can hear the music of the Sirens and live. That’s a form of self-paternalism, but it isn’t what I’ve done. I want to understand the treatment possibilities that may be available, so along with Teresa I’ve been learning about cholangiocarcinoma and the expanding range of medical responses to it. The studies and talks I’ve looked at describe the likely outcomes clearly, and Teresa and I discuss them carefully. So I am not hiding from knowledge. What I am doing is, as well as I can, directing my attention to life.