Chemotherapy and its risks for those who administer it

A moment during chemotherapy two weeks ago: the nurse who was about to hook up the plastic bag containing my gemcitabine dose paused to first put on a medical gown. Teresa tells me she’s seen a couple of other nurses do this, but it doesn't seem to be common. Why did this nurse put on the gown? The answer, as she explained, is that it’s a precaution against contact with the gemcitabine. She herself had spilled gemcitabine on her arm at some point, and despite washing her arm quickly, she wound up with a burn on her skin – and that was from just a brief exposure to the drug.

She went on to explain to us that Memorial Sloan Kettering is engaged in a study of the effects of staff members' long-term exposure to chemotherapy drugs. That kind of exposure can be the result of spillage, but also can come from the vaporizing of tiny quantities of the drug during the process of intravenous infusion. In an earlier post I mentioned the new valve we saw not too long ago, used on the IV line in an effort to prevent this vaporizing. Between the valve and the gowns it seems that quite a bit of care is now being taken to protect the nurses, but it’s striking that these steps seem to be quite recent. Was this risk overlooked in the past? Or, on the other hand, is it being overstated now? In our experience, most nurses don’t seem to use the gowns; whether that reflects the power of habit, or the nurses’ lack of time, or instead attests to their sense that the gowns are an unnecessary precaution I don’t know.

The fact is that no one can know very much about this long-term risk, because chemotherapy itself hasn’t been around that long. In effect, the nurses are part of a life experiment to find out what the risks are.

Medical marijuana -- and what we aren't learning about it

Today’s New York Times has an editorial about the United States’ bizarre unwillingness to permit regular scientific research on medical marijuana. I’m no expert on this area of public policy, but I am getting interested in medical marijuana as a response to pain, and the Times reports that a National Academy of Sciences report from last week "found 'conclusive or substantial evidence' that marijuana or compounds in the plant can effectively treat chronic pain, nausea from chemotherapy and some symptoms of multiple sclerosis." 

So I want to second the Times’ editorial, based on what the pain management person we work with at Memorial Sloan Kettering -- a nurse practitioner -- told me yesterday. What she said is that there is no research on dosage levels for medical marijuana. But obviously different amounts of the drug will have different effects, both positive and negative. How are patients supposed to figure out the right dose? (That's assuming they can work their way through the bureaucratic obstacles state law may erect in the way of access to the drug -- in New Jersey's case, pretty substantial obstacles.) Apparently the answer is: without the aid of science. This is, to put the point gently, crazy.

The business of cancer treatment

Our local newspaper, The Star-Ledger, recently reported on a coming change in cancer care in New Jersey (Kelly Heyboer & Kathleen O’Brien, “‘Historic’ deal gives N.J. cancer patients more experimental treatment options,” published as “Deal promises big upgrade to N.J. cancer care” in The Star-Ledger, Dec. 15, 2016, at 1.)

This really is a big deal. It creates a partnership between Hackensack Meridian Health, described as “one of New Jersey’s largest hospital systems,” and Memorial Sloan Kettering Cancer Center. The article reports that it “will affect about one in every five cancer patients in New Jersey, company officials said.” New Jersey patients being treated by Hackensack, or at least some of them – the article isn’t clear on this point – will evidently now have access to Sloan Kettering’s clinical trials. In addition, “[d]octors from both organizations will participate in joint tumor boards and other meetings to help chart treatment courses for patients. The two sides will also establish joint standards of care for patients.” There’s also a medical school tie-in: “[s]tudents at the new Seton Hall-Hackensack Meridian School of Medicine, set to open in Nutley [a North Jersey town] next year, will have opportunities to train at Memorial Sloan Kettering facilities.”

I’m already a Sloan Kettering patient. Teresa and I long ago decided that it was worth our time and expense to travel into Manhattan every week or two for treatment. But there are many reasons why other New Jersey patients might not make that same choice – and yet they could benefit from Sloan Kettering’s expertise. So it seems to me that this partnership should tend to improve treatment for many people. But while Teresa and I have a lot of respect for Sloan Kettering as an institution, we also have a lot of respect for our individual oncologist. She practices in Manhattan; if you want to see her, you have to go to Manhattan. Even before this deal was made, Sloan Kettering offered treatment at a site of its own in Basking Ridge, N.J.; that wouldn’t have been much more convenient to us than Manhattan, but even if it had been, we wouldn’t have switched facilities because it would have meant switching doctors – and that would have been entirely within Sloan Kettering. So I’m just not sure how easily the skills and attitudes that make our Manhattan oncologist impressive will transfer from institution to institution.

This deal isn’t only about benefits to patients, however. It is also about benefits to institutions. As the article says, “[t]he combined organizations will create the largest cancer care network in the region and one of the largest in the country.” It seems that some of the nation’s leading cancer treatment institutions are looking for markets, and that they see New Jersey as full of opportunity. Even before it reached this deal with Hackensack Meridian, Sloan Kettering was developing two more sites of its own in New Jersey. I understand that Sloan Kettering also has sites in Westchester County, north of New York City, and on Long Island. Sloan Kettering seems to be aiming to become a regional treatment center. But at least one other leading cancer treatment center has even broader ambitions than that. The article reports that “[a]nother competitor, the MD Anderson Cancer Center in Houston, is also expanding to have a national footprint. It has partnered with the largest collective physicians’ practice in [New Jersey], Summit Medical Group, to provide cancer care in New Jersey under the Anderson name.” 

It’s clear that cancer treatment is a big, competitive business, and that the powerhouse institutions in this field are moving to extend their reach. That may well be good for patients – but I’m sure that individual patients will still want to find doctors whom they can rely on, and I don’t think that the many doctors who in the future may be grouped under prominent institutional brand names will all be fungible.