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Most people want to fend off death no matter the cost. More than $40
billion is spent worldwide each year on cancer drugs. In the United
States, they constitute the second-largest category of pharmaceutical
sales, after heart drugs, and are growing twice as fast as the rest
of the market. The bulk of this spending goes to chemotherapy, which
is used in a variety of ways and has proven effective on some cancers,
including leukemia, lymphoma, Hodgkin's disease, and testicular cancer,
especially if these cancers are detected early.
But in most other cases, chemotherapy is remarkably ineffective. An exhaustive analysis of cancer treatment in the United States and Australia showed that the five-year survival rate for all patients was about 63 percent but that chemotherapy contributed barely 2 percent to this result. There is a long list of cancers for which chemotherapy had zero discernible effect, including multiple myeloma, soft-tissue sarcoma, melanoma of the skin, and cancers of the pancreas, uterus, prostate, bladder, and kidney. Consider lung cancer, by far the most prevalent fatal cancer, killing more than 150,000 people a year in the United States. A typical chemotherapy regime for non-small-cell lung cancer costs more than $40,000 but helps extend a patient's life by an average of just two months. Thomas J. Smith, a highly regarded oncology researcher and clinician at Virginia Commonwealth University, examined a promising new chemotherapy treatment for metastasized breast cancer and found that each additional year of healthy life gained from it costs $360,000--if such a gain could actually be had. Unfortunately, it couldn't: the new treatment extended a patient's life by less than two months. Costs like these put a tremendous strain on the entire health-care system. Smith points out that cancer patients make up 20 percent of Medicare cases but consume 40 percent of the Medicare drug budget. Some oncologists argue that the benefits of chemotherapy aren't necessarily captured in the mortality data, and that while chemotherapy may not help nine out of ten patients, it may do wonders for the tenth. Still, considering its expense, its frequent lack of efficacy, and its toxicity--nearly 30 percent of the lung cancer patients on one protocol stopped treatment rather than live with its brutal side effects--why is chemotherapy so widely administered? The profit motive is certainly a factor. Doctors are, after all, human beings who respond to incentives. Oncologists are among the highest-paid doctors, their salaries increasing faster than any other specialists', and they typically derive more than half of their income from selling and administering chemotherapy drugs. Chemotherapy can also help oncologists inflate their survival-rate data. It may not seem all that valuable to give a late-stage victim of lung cancer an extra two months to live, but perhaps the patient was only expected to live four months anyway. On paper, this will look like an impressive feat: the doctor extended the patient's remaining life by 50 percent. Tom Smith doesn't discount either of these reasons, but he provides two more. It is tempting, he says, for oncologists to overstate--or perhaps over-believe in--the efficacy of chemotherapy. "If your slogan is 'We're winning the war on cancer,' that gets you press and charitable donations and money from Congress," he says. "If your slogan is 'We're still getting our butts kicked by cancer but not as bad as we used to,' thats a different sell. The reality is that for most people with solid tumors--brain, breast, prostate, lung--we aren't getting our butts kicked as badly, but we haven't made much progress." There's also the fact that oncologists are, once again, human beings who have to tell other human beings they are dying and that, sadly, there isn't much to be done about it. "Doctors like me find it incredibly hard to tell people the very bad news," Smith says, "and how ineffective our medicines sometimes are." If this task is so hard for doctors, surely it must also be hard for the politicians and insurance executives who subsidize the widespread use of chemotherapy. Despite the mountain of negative evidence, chemotherapy seems to afford cancer patients their last, best hope to nurse what Smith calls "the deep and abiding desire not to be dead." Still, it is easy to envision a point in the future, perhaps fifty years from now, when we collectively look back at the early twenty-first century's cutting-edge cancer treatments and say: We were giving our patients what? |
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You are like the poster child for the theme from Friends:
"Not your day, your week, your month, or even your year."
Somewhere there's a voodoo doll absently tossed into a drawer full of icepicks. That, or you really need to look into past-life therapy and figure out which gods you pissed off. |
| I know it is coming, and I do not fear it, because I believe there is nothing on the other side of death to fear. I hope to be spared as much pain as possible on the approach path. I was perfectly content before I was born, and I think of death as the same state. What I am grateful for is the gift of intelligence, and for life, love, wonder, and laughter. You can't say it wasn't interesting. My lifetime's memories are what I have brought home from the trip. I will require them for eternity no more than that little souvenir of the Eiffel Tower I brought home from Paris. |
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So, how's that whiney thing working out for you??
Some random thoughts (my specialty!) before I go take my nap. One of my clients just decided that a document I shouldn't have had to worry about until June is now past due. Those of us who haven't learned our life expectancy can't decide which balls we don't need to juggle anymore. We need to behave as though we will need to continue providing food and shelter for our families for the next couple of decades. Don't confuse the long silences with lack of concern, or we will start telling you just how much your situation affects our lives, and how unbelievably you will be missed. You just blew a chance to put your point across much more effectively by playing the sage and advising us to look at our own, current situations objectively, so that we can look back on them, years from now, when we are -- as we will be -- in your situation, and, remembering what it was like, be more understanding of the people who aren't able to come visit us. You won't be nearly as lonely in the hospice, because there will be other people around! Of course, they'll all be whiney little -- you know, it's amazing how much of our vocabulary orbits the seventh planet -- farts, but hey. |
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