Recently by Michael Fisch M.D.

 Have you noticed how often the media and online world is bombarding you with information about testosterone?  LowT_Fisch.jpg

Whether it is a reference to banned substances used by athletes, something that men wish they had more of in their aging bodies, or something having to do with the biology and treatment of cancer, it seems to happen with increasing frequency.

This week, in the journal Cancer another angle on the testosterone story comes forth--the idea that testosterone deficiency can result as the unintended and surprising consequence a new and effective cancer treatment. 

Specifically, researchers from the University of Colorado found that crizotinib, the new pill approved by the FDA, because it effectively treats the small subset of non-small cell lung cancer patients (4-7% of patients) who have a specific molecular aberration in the ALK gene, causes rapid suppression of testosterone levels.  Those levels come back to normal when the crizotinib is stopped. 

Here are 4 things that you might want to know to understand this testosterone issue in a broader context:

Look at the Strings

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strings.jpgWith so many transformations in health care, it sometimes seems that the world is spinning faster. To organize each hectic day, I think about it like it's a string. 

My strategy for dividing the string into various fragments is important. You need string of a certain quality and length to do things that require deep thought, like writing a paper or making major strategic or personal decisions. 

Other things, like signing routine documents or filing things, can be accomplished using the lower quality portion of the string (i.e., the fragmented string toward the end of a long day).

This idea of strings -- what one faculty colleague called my "string theory" -- triggered a memory of a patient who told me an inspiring story. Inspirations are a gift shared by so many patients and part of the huge privilege of being a physician.

Here is the story that I recalled: "Look at the Strings."

Mr. Z. was a liberal arts professor with widespread cancer, in the midst of chemotherapy. A subspecialist colleague called to ask if I'd see this patient who seemed to have a distinctly profound problem with fatigue.

Photo by © ASCO/Todd Buchanan 2011

ASCOFloor_edit.jpgEvery year around this time, there's a scheduled pilgrimage for clinical oncologists. From all over the world they flock, young and old, to attend the Annual Meeting of the American Society of Clinical Oncology (ASCO). 

Although the attendance numbers vary from year to year, there is on the order of 25,000 professional attendees and about 4,500 scientific abstracts available for review and discussion. As I prepare to return home to Houston after this 2011 meeting, I have the familiar mixed feeling of inspiration and physical exhaustion.

The exhaustion is easy to understand. Each day, there are innumerable scientific and educational sessions integral to the ASCO meeting itself. Then there are side meetings with other agencies, institutions or colleagues planning and monitoring various projects. In addition, more meetings with friends and mentors who are treasured yet seldom seen in the ordinary flow of a frenetic work life. 

What about this experience was so inspiring? 

I think that any statement about major advances in cancer care ought to be comprehensive and carefully considered. I find it particularly useful to reflect on what we mean when we call something an "advance." Here are some categories that I used to sort out different kinds of advances.

  • Category A: Advances where some new, proof-of-principle in science was demonstrated; a breakthrough in scientific terms.
  • Category B: Advances that have major impact on lives or patterns of care, either due to the large number of affected patients or the large magnitude of change in the outcome or pattern of care.
  • Category C: Advances that are generally encouraging signs of progress. This is where most of the advances would be categorized, in my opinion. These are findings affecting fewer patients, influencing fewer life-years or producing generally less dramatic changes. Some of these advances are of greater interest to the lay population because of business implications or because they address topics of broad interest or shared experience.

Examples of Category A advances include the work with PARP inhibitors for selected patients with breast cancer in 2009, and the work with the new oral ALK inhibitor (crizotinib) for lung cancer patients in 2010 . These represent a new category of treatment for a subset of patients with common diseases. 

Previously, when the first breakthrough targeted therapy came along in the form of Imatinib (Gleevec), it was a story of major impact in rare diseases like chronic myelogenous leukemia (CML) or gastrointestinal stromal tumor (GIST).   In 2010, the new rare disease breakthroughs include vandetanib, an oral targeted agent for metastatic medullary thyroid cancer and everolimus, recently shown to dramatically improve progression free survival for pancreatic neuroendocrine tumors. When we're talking about a small subset of common diseases, it creates a new dilemma -- how do we screen all of these patients with common diseases to find the subsets of patients who would dramatically benefit from specific targeted therapy? It will take a lot of money, technology, and infrastructure change to accommodate the personalized cancer care approach. It is fascinating, exciting, and still daunting.

On the more positive side in Category B was the finding that the early integration of palliative care in patients with advanced lung cancer was associated with not only improved quality of life and decreased intensity of common symptoms, but also an increase in survival of 2.7 months.  This is the magnitude of survival benefit that is similar to that seen when chemotherapy was compared to not using chemotherapy. It was also demonstrated recently that physician-patient communication towards the end of life was associated with patient choices that lead to improved end-of-life care quality and value

Some of the Category B level "advances" represent disappointing, albeit important news. For example, the findings from the SELECT trial reported in December of 2008 demonstrated that vitamin E and selenium do not prevent prostate cancer. Similarly, we found 3 months later, in March of 2009,  that PSA screening does not effectively save lives in the way that we had hoped.

Finally, we learned in 2009 that the expensive monoclonal antibody, bevacizumab, while effective as part of the regimen treating advanced colon cancer, is not actually useful as part of a strategy to prevent recurrence of colon cancer once it's been removed.  Furthermore, in June of 2010 (also at the ASCO annual meeting) we found out that there is no benefit to adding cetuximab, a different monoclonal antibody therapy, with this same goal of preventing recurrent disease.  Ironically, the feelings about that news was somewhat mixed for oncologists. On one hand, oncologists always want to see positive findings about new therapies, but some oncologists also noted that the overall health care expense associated with a positive finding on these particular studies may have created some real dilemmas.

So what needs to be done to create a world in which more category A and B (high impact) findings are produced, where the bulk of the advances are no longer stacked up in Category C (lower impact)?  The cancer research world needs a better engine and more fuel, and that's where organizations like ASCO are perfectly on target with their recommendations.

The "engine" is the clinical research infrastructure, and it's an old and inefficient engine that needs to be fundamentally reformed according  to a report of the Institute of Medicine issued in April of this year. The "fuel" is the funding, and fuel is necessary for any engine to run. With expected large increases in the relative impact of cancer on the nation and its health and finances, the time for fueling up a fixed engine is now upon us.

Like my colleagues, I'm an avid reader of medical journals as I try to understand and incorporate all the latest advances in cancer medicine.

In the April Journal of Clinical Oncology, in addition to the usual scientific contributions, I found a poignant essay written by a physician in India called "Life's lesson lost ... and learned." The author focuses on what she learned from a 12-year-old girl who lost her mother to breast cancer.

Ironically, this essay actually reminded me of our Making Cancer History campaign. You may have seen this on television or on our website, with all the inspiring stories of individuals who have been cured of malignant diseases and have their picture shown with a red line drawn through the name of their cancer. 

The essay in the Journal of Clinical Oncology reminded me that one can be part of Making Cancer History in many different ways, and becoming a patient cured of cancer is one fabulous pathway but not the only way. Imagine a person in the campaign with a red line through the phrase "cancer pain" or "hopelessness," or something else that's an eradicable source of suffering that extends beyond the tumor's mere existence.

Let me propose three additional pathways on the road to Making Cancer History: 

1.    Making ambitious but appropriate goals in the face of cancer and reaching them.
2.    Giving the gift of the "teachable moment" to share with family, friends and the medical team.
3.    Discovering ways to reach outside of our institutional structure to make something extraordinary happen for patients with cancer or risk of cancer.

Here are some specific illustrations for each additional pathway.

pamandjimMaking ambitious but appropriate goals

Ms. June Stokes is a long-term survivor of stage III ovarian cancer, and we have stayed in close touch over the years.

Her cousin, Jim McArthur, is from Glenmora, La. He was principal of Glenmora High School and his wife, Pam, was a teacher at the high school. 

Unfortunately, Pam became ill shortly after her youngest of three daughters was married. She died on Nov. 20 at the age of 56, about 23 months after being diagnosed and cared for at MD Anderson for a rare form of malignancy. About six months before she died, Pam developed kidney failure requiring dialysis. She recovered at home for about two additional months, and then she set some goals for things that she wanted to achieve toward the end of life. 

1)  She wanted to get strong enough to fly to Canada and visit her youngest daughter and get to see where she lived and meet the in-laws. Accomplished!

2)  She wanted to go to New York City and see a play on Broadway. Accomplished!

3)  And most of all, she wanted to get strong enough to return to MD Anderson and WALK into the department where she had received amazing care for weeks. Accomplished!

Ms. Stokes described this inspiring course, writing to me by e-mail that, "The staff on the floor who had taken care of her were speechless when she came walking in. It was really a miracle. And that was her main wish for when she was discharged from MD Anderson -- everything that could be done had been done. The staff called her 'their angel.'"

The gift of the teachable moment

Another example is Mr. Doan Nong, a 78-year-old man from Houston. Mr. Nong died on Easter Sunday, about one month after I first met him at MD Anderson when he came for an outpatient visit and soon learned that he had advanced liver cancer.

He had significant pain, but he had a remarkable zest for life and he was eager to receive therapy for this malignancy. Unfortunately, the medical circumstances did not allow him to begin the prescribed treatment, but he was able to achieve good pain control and he ultimately died peacefully and surrounded by his loving family at home with the assistance of hospice. 

Mr. Nong and his family, in my mind, contributed to Making Cancer History. He contributed the gift of the teachable moment. The lessons learned were not related to illness or even the biology and treatment of cancer symptoms. The real lesson here is a man's striving for life in the face of difficult circumstances, his incredible loyalty and love for his family, and the downstream legacy of loyalty and love reflected back to him by so many. 

His story of personal courage as a war veteran and prisoner of war is one of many things about him that I did not comprehend until I attended his funeral. As his oncologist, I was privileged to get to know him, his story and his inspiring family to share in Making Cancer History through receipt of the teachable moment.

Reaching outside of our institution to make something extraordinary happen

And my final example relates to some inspiring colleagues at MD Anderson who work in the Division of Cancer Prevention and Population Sciences, Department of Health Disparities.  Beverly Gor, Ed.D., and Lynne Nguyen work in different programs in their department, but they worked together as community volunteers to develop a dream. 

Spending many hours of their time along with their friend, Mrs. Rogene Calvert, they worked through the Asian-American Health Coalition and in 2001 realized their dream of creating a new medical clinic. The Hope Clinic was created to provide affordable care for many vulnerable individuals and families in West Houston. 

hopeclinic_edit.jpgBy 2008, the Hope Clinic received funding as a federally qualified health center, and they have received other significant grants from foundations and the state of Texas to further improve patient care. Among other things, this clinic is unique in having developed funding to screen patients for hepatitis B and help take steps to treat and prevent this condition that puts patients at risk for liver cancer.

See the report from My Fox Houston about the Hope Clinic:

The great thing about MD Anderson is that Making Cancer History is something that happens in so many ways, every day, through the inspiring efforts of doctors, nurses, scientists, patients, families, community leaders and countless others.

My Valentine's Wish for 2010

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My birthday is on the 11th, my mom's is on the 12th, my brother's is on the 13th and my father's is on the 14th -- all in different months. Since my dad's birthday is in February, my Valentine's Day reflections are for him.

At M. D. Anderson we're always focused on doing the very best for our patients. Ingrained in this notion of providing the "best" possible care is feeling unsatisfied when our treatment doesn't routinely produce the outcome we strive for -- cure of disease with outstanding quality of life and function in survivorship.

Because we're unsatisfied, we strive for better care through research and by rapidly and skillfully applying new advances in cancer medicine to the care of our patients. How do we sort out the most important new advances in cancer care from those that are less important or more uncertain? Here are some categories that come to mind:

Category A -- advances where some new, proof-of-principle in science is demonstrated. A breakthrough in scientific terms.

Category B -- advances that have major impact on lives or patterns of care, either due to the large number of affected patients or the large magnitude of change in the outcome or pattern of care.

Category C -- advances that are generally encouraging signs of progress. This is where most advances would be categorized, in my opinion. These are findings that affect fewer patients, influence fewer life-years or produce generally less dramatic changes. Some of this category's advances are of greater interest to the average non-physician because they address topics of broad interest or shared experience, or because there are business implications.

An example of a Category A advance, in my mind, is the work with PARP inhibitors (such as BSI-201) for selected patients with breast cancer. This represents a new category of treatment for a very difficult-to-treat subset of this common disease. This was a plenary session presentation at the 2010 annual meeting of the American Society of Clinical Oncology (ASCO), which reflects the scientific importance of this particular advance.

On the more positive side in Category B is the finding that testing tumors of patients with adenocarcinoma of the lung for specific mutations is likely to guide the best choice of treatment. It also was demonstrated this year that physician-patient communication near end of life is associated with patient choices that lead to improved end-of-life care quality and value.  

Some Category B level "advances" represent disappointing, albeit important news. For example, findings from the SELECT trial reported this year demonstrated that vitamin E and selenium do not prevent prostate cancer. We also learned that PSA screening does not effectively save lives in the way that we had hoped. Finally, we learned that the expensive monoclonal antibody bevacizumab -- while effective as part of the regimen treating advanced colon cancer -- is not actually useful as part of a strategy to prevent recurrence of colon cancer once it's been removed.

Ironically, feelings about that news was somewhat mixed for oncologists. On one hand, oncologists always want to see positive findings about new therapies. But importantly, we all want to know the truth about what really works and what does not. Many specialists also noted that overall health care expenses associated with a positive finding on this particular study may have created some real dilemmas.

With Valentine's Day approaching and so many loved ones (living and deceased) on my mind, I can't help but dream of new horizons. Like so many others, my heart has suffered losses attributable to cancer.

So what needs to be done to create a world in which more category A and B (high-impact) findings are produced, where the bulk of the advances are no longer stacked up in Category C (lower impact)? The cancer research world needs a better engine and more fuel.

The "engine" is the clinical research infrastructure, and that is an old and inefficient engine that needs to be fundamentally reformed. The "fuel" is the funding, and that fuel is necessary for any engine to run.

With expected large increases in the relative impact of cancer on the nation and its health and finances, the time for heartfelt focus on fueling up a fixed engine is now upon us.

Sitting with the boys from Little League and their parents on Saturday night, a parent (and friend) surprised me when he said, "I know a lot about your Dad." He told me my Dad's name and he knew that his birthday was on Valentine's Day. It turns out that he had met the spouse of a former patient of mine, and she remembered me fondly and recalled this information that I had shared. I wondered ... what was the context for me sharing this about my Dad and was that appropriate?

The next morning, I read the front page article in the New York Times about M. D. Anderson Cancer Center. The question on my mind after reading this article is whether or not the story captured the essence of our top-ranked institution. 

There are many perspectives on the story, depending on whether you talk to faculty and staff or patients familiar with M. D. Anderson, or other people who are mesmerized by the story but unfamiliar with our center. To me, of the images and various vignettes in the story, the most striking was that of a singular mission -- to eliminate cancer in Texas, the nation and the world -- and an ambitious and compassionate approach.

The nurse (Cindy Davis) and the physicians (Marty Raber and Patrick Hwu) featured were all intimately connected to their patients, striving to do everything in their power and professional scope to understand their patients in all possible dimensions, and most of all to help. The mission was personal to each of them, and this is how things go around here.

feelingsman.jpgI wrote in an earlier post about the concept of buoyancy (the force that keeps us afloat) and some of the factors that this force has in each of us. To me, compassion is derived from the combination of our own buoyancy plus empathy (the process of understanding and being sensitive to the experience and feelings of another). As such, it's important to bring something of ourselves in order to be fully compassionate.

The idea of sharing something intimate, as a physician, can be humanizing and helpful to our patients. This was discussed in the New York Times wellness blog, and there was a strong acknowledgement that it can be an important and useful feature in caring for patients (as long as the intent and ultimate focus is squarely with the patient).

As I sit in my office and watch the storms approach here in Houston, I think I understand a bit better why I might have shared something intimate with a patient about my Dad. 


What I noticed the First Time I Saw Patients on Rounds as a Medical Student

MFisch.BayArea_clinic.jpgOn a rainy weekend, I spent a few minutes looking through an old photo album with my kids. Tucked away in a folder within one album were letters that I shared with my parents during medical school. My mom, who died of lung cancer in 2006, had saved these letters.

One letter was written to a wonderful physician and mentor who allowed me to go on infectious disease rounds with him on a Saturday morning for the very first time, during my first month in medical school when everything was about book learning. I found a "thank you" letter to my mentor, Dr. Barry Farr, dated Oct. 27, 1986. In the second paragraph of my letter, I wrote:

I want to share with you some of the things that I learned on Saturday that I otherwise would not have known. I think that this may be interesting for you because it seems that physicians (and other medical students) do not always remember exactly what they did and didn't know when they were first-year students.

In the ensuing paragraphs, I listed seven categories of my observations. Topic six was about vocabulary:

I realized that my ability to understand what was going on hinged on my familiarity with the vocabulary. One way to categorize the vocabulary might be as follows:
a) Anatomical vocabulary (i.e. fourth metatarsal)
b) Vocabulary of disease (i.e. osteomyelitis)
c) Vocabulary of clinical medicine (i.e. nosocomial, iatrogenic)
d) Current jargon (i.e. "LCM," "PTC")

As you may recall, I think that one of Yogi Berra's quotes may apply here (if adapted to medicine). He said something to the effect that "Half of baseball is 50% mental." This can be adapted to read "Half of medicine is 50% vocabulary."

The following week after finding this old letter, a colleague, Dr. Daniel Epner, shared with me his correspondence with Dr. John Mendelsohn, M. D. Anderson's president, regarding his reflections on health care reform. Dr. Epner wrote:

... Many challenges that we face on a daily basis that we think of as biomedical, technical or logistical issues are essentially communication issues. For instance, I hypothesize that we can improve care tremendously and avoid uncomfortable and futile interventions at the end of life by implementing improved communication protocols and procedures that focus on discussions of goals of care throughout the spectrum of illness. ...

The key point from Dr. Epner is the focus on goals of care and attention to the topic of physician-patient communication. Nevertheless, the vocabulary of medicine itself is one part of the challenge in communication, and it is all too easy to forget when we, in health care, didn't understand all of these words (as I noted to Dr. Farr after my very first rounds).

fisch_signingFor some reason, I have a track record for working in areas of cancer medicine that are fundamentally patient-centered, difficult to understand based on their labels and challenging to briefly explain. Three examples: palliative care, general oncology and integrative medicine. What do these topic areas mean to you? 

I arrived at M. D. Anderson in November 1999. I had been trained in internal medicine and hematology/oncology, and had spent the first two years of my career as an academic oncologist focusing on the care of genitourinary malignancies. But I had decided to pursue my interests in issues related to symptom management and quality of life, so my job position here was in the Department of Palliative Care and Rehabilitation.

The department was new, and I would be asked by faculty and staff on a frequent basis, "what is palliative care, anyway?" I would babble something about quality of life and helping people live better, but I couldn't explain it coherently before the questioning colleague got off the elevator or veered in a different direction. So I decided to find a succinct definition that I liked, and rehearse and memorize a version of it. Here's what I memorized:

"Palliative care is comprehensive, interdisciplinary care for patients with life-limiting illness, where the focus of care is enhancing quality of life and reducing suffering for the patient and family."

OK, so what's general oncology? It's the ultimate paradox at our institution, which is well known for incredible subspecialty expertise in so many areas. Why would M. D. Anderson want "general oncology?"

On our main campus, general oncologists have a role in the initial evaluation of complex international patients as they're evaluated and cared for in preparation for the appropriate subspecialty, multidisciplinary team. Moreover, they're often called upon to help navigate complex care when multiple specialty teams are involved. General oncologists provide care in our Integrative Medicine Clinic as well.

Our Department of General Oncology leads the medical oncology care at Lyndon B. Johnson General Hospital and at our community-based clinical care centers. Also, general oncologists often lead and participate in patient-oriented research projects and clinical trials that address issues cutting across different diseases, and collaborate on other projects and clinical trials that are led by subspecialists.

Finally, if general oncologists evaluate patients in the Integrative Medicine Clinic, what exactly is integrative medicine? According to the Consortium of Academic Centers in Integrative Medicine, it's "the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals and disciplines to achieve optimal health and healing."

To me, that sounds exactly like good medical care -- just the kind of patient-centered care that people expect. The thrust of the care in integrative medicine is tailoring to each individual patient a program that improves his or her health and well-being, above and beyond the disease-focused expert care provided by other care teams.

My aunt left me a message last night while I was umpiring a Little League Baseball game. While I was enjoying watching 8-year-old boys show their skills on the ballfield, she was calling to let me know that her cancer has returned. She wanted to know about her treatment options for the difficult disease that has come back, despite her previous surgery and radiation therapy.  

She lives in another city, and her excellent team of cancer specialists discussed with her the choice of a standard treatment regimen of chemotherapy compared to a clinical trial. The trial option involves allowing the treatment choice to be randomly assigned (by a computer) to a new cancer treatment pill (taken alone) versus a combination of the new agent and some other commonly used medications.

So what help could I offer her in making this decision? What is the formula going through my mind?

clinical trials = discovery = hope = quality care in medical oncology

While this isn't the key equation in all other disciplines (such as pathology, surgery, family medicine, etc.), the discipline of medical oncology is different in this regard. Clinical trials are what nourish medical oncologists and patients in the research-driven patient care model.

Clinical trials are critical to the international patients we care for at M. D. Anderson and to our patients who choose to receive care at our satellite centers in the community, much in the same way as they're important to patients who we care for at our main campus in the Texas Medical Center in Houston, Texas. All of these groups are more similar than different.

Even if only a portion of patients choose to enroll in our trials, it's the HOPE that emanates from the trial menu and related discussions about discovery that sustains the magic of M. D. Anderson Cancer Center and the power of change in outcomes related to cancer care.

Michael Fisch, M.D., chair of M. D. Anderson's Department of General Oncology, was asked in a recent WebMD article on Farrah Fawcett's choice to seek cancer care in Germany to provide suggestions to patients considering leaving the country for cancer care. In the article he recommends that patients:

•    Define and prioritize goals
•    Discuss those goals with a doctor
•    Don't take good care for granted
•    Consider their own backyard
•    Recognize their vulnerability

In this video, Dr. Fisch expands on his thoughts about making the choice to explore alternative care outside of the United States. .

Source: WebMD

Fisch_explaining.jpgThe patient had been perfectly healthy and now he had this new diagnosis of cancer. Now he is just miserable. And I reflect not only on the details about the disease and treatment, and the facts about treatment goals and prognosis, but I wonder how he can restore a sense of "buoyancy" (that force that keeps one afloat as opposed to sinking)?

I'm a cancer physician, not a pop-psychologist, but nevertheless I find it useful to get my own clear sense of buoyancy -- to understand my patients and to understand myself, too. I've decided that these 10 parameters (specific "floaties") are most important. They're in no particular order, they don't have equal importance, and their contributions to my overall buoyancy vary over time.

  1. Autonomy (freedom to choose). It's good not to be told how to act, dress or do every little thing at work.
  2. Exercise my skill (do my thing). I love being a cancer physician.
  3. Establish and maintain meaningful relationships. This applies for all aspects of my life (work, family, other activities).
  4. Being awake to my present reality. That means knowing that I'm not an astronaut, but also being able to tell when I'm tired or hungry or angry.
  5. Gratitude. The glass must be half full, at some level.  
  6. Courage (managing fear). There's no avoiding fear and doubt.
  7. Appreciation of impermanence. This just means that I "get it," that all things change. I may not relish change in all instances (like my aging body or my changing bank account in this economy), but I can see this truth.
  8. Compassionate mind frame. Empathy with benevolent intent.
  9. Finding and keeping my safety and security. This varies for each person. It might be a religious thing for some, or it could be related to having enough money or living close to family. It's that grab bag of individual stuff.
  10. Answering the question "do I matter?" This could be the ultimate existential question at some level, or it may apply in smaller situations (like "do I matter" on this project, or coaching this kids' soccer team, etc.).


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