April, 2014

Midlife Crisis

By Michael J. Katin, MD

Anniversaries happen every day, which makes Hallmark very happy, but there are some that are so much more profound than others. It was only fifty years ago this month that one of the seminal events in world history occurred. In addition, only two day earlier, a dedicated group of individuals met to form an organization that has thrived to the point that it is the foremost of its kind in the world today.

So it was that on April 5, 1964, that the organizational meeting of the Society of Broadcast Engineers (SBE ) was held at the Conrad Hilton Hotel in Chicago, Illinois. They were no doubt distracted by the fact that the previous day the Beatles took over the first five spots in the Billboard Hot 100 listing, the only recording artists ever to do this. The excitement of the founding of SBE was probably tempered by the fact that General Douglas MacArthur had passed away on that day. With all these events ongoing, it would seem probable that they did not take note that making their way to Chicago were a group of physicians and researchers who had self-directed themselves into the field of cancer treatment, preparing to meet on April 9 at the Edgewater Beach Hotel in that very same city.

It was on that day that Drs. Fred Ansfield, Harry Bisel, Herman Freckman, Arnoldus Goudsmit, Jane Wright, William Wilson, and Robert Talley met for lunch and the American Society for Clinical Oncology was born, somewhere between the entrée and dessert.

This was a tumultuous time in world history. There was turmoil in the United States between those who distrusted the government and those in power. The Union of Soviet Socialist Republics was on a mission to aggressively expand its influence across the rest of the world. Warnings of the effects of climate change were being heard. The President of the United States was making proposals to lift the disadvantaged of this country out of poverty. How things have changed!

Medical treatment in general, and cancer care especially, was primitive. The most active drug was nitrogen mustard, and the biggest breakthrough in radiation therapy (run by diagnostic radiologists with a special interest in cancer treatment) was teletherapy with cobalt-60, in very few locations, and the Betatron. Life expectancy was 73.7 years for women and 66.9 years for men.

What a difference 50 years can make! Molecular profiling has made individualized treatment possible. New systemic agents are being approved almost daily. It is considered routine for radiation therapy to be delivered by technologically-advanced linear accelerators, and proton and other treatment modalities are becoming more common. Life expectancy is 80.9 years for women and 76.0 years for men. Little did the founders of ASCO know what an impact their lunch meeting would have on the health and longevity of the American public (recognizing, of course, some modest gains from progress in treating other medical conditions,

Although phenomenal breakthroughs have occurred in diagnosis and treatment of cancer, thanks to the organization of medical oncology as a specialty, another event from the 1960's has to be recognized. In the year following that fateful lunch in Chicago, Medicare was signed into law on July 30, 1965. Medicare allowed the expansion of services to senior citizens who otherwise would not have been able to afford increasingly sophisticated and increasingly expensive treatments. Ironically, the success of these treatments has led to heightened expectations and longer survivals, resulting in generation of increased expenditures over a person's lifespan, producing calls for cutbacks in paying for increasingly sophisticated and increasingly expensive treatments for cancer as well as other conditions.

What to do about this? Fortunately, ASCO has come through. Keeping in mind that ASCO is 50 years old, it would be understood if it were to become act like any other 50-year-old. We might next see ASCO growing a pony tail, buying a motorcycle, or trying to start an affair with the American College of Epidemiology or one of the other younger organizations. Considering what other institutions are becoming 50 years old this year (i.e., Keanu Reeves, Matt Dillon, and Nicholas Cage ) it would not be unexpected for ASCO to move in an unpredictable course. Instead, ASCO has risen to the occasion, big-time!

Due to coverage of other important events, the news media seemed to have missed the release of ASCO's manifesto on March 11, The State of Cancer Care in America, 2014. This document called attention to the rising need for cancer-related services (an increase by 42% by 2025) and the lack of increase in oncology-related practitioners to deal with this. Considering the aging of the population the number of new cases of cancer will increase by 45% by 2030 and there will be 18 million cancer survivors by 2022, who would benefit from specialized monitoring for recurrence and long-term effects of treatment. ASCO predicts that the supply on oncologists will grow by only 28%, and calls attention to the fact that more than 70% of counties in the United States do not have a single medical oncologist!!!! Granted that the United States has 3,141 counties or county equivalents, with extreme variability in cancer incidence compared to average, and that it is probable that more than 70% of counties in the United States don't have a Walmart, this may not be the best statistic to emphasize. In any event, ASCO has made recommendations for government policies to address this impending crisis, and it is hoped that attention of the public and politicians will be able to be redirected before it is too late. There has been too much of an effort to try to cut down on costs of health care, and we're usually on the defensive. We have needs, and we have resources. It's all a matter of resetting priorities.

If all the energy, time, and expense dedicated to figuring out the financial repercussions from the government side, insurers, and practitioners, were dedicated to patient care, maybe there wouldn't be a problem. The monthly amount spent to keep a patient supplied with Sutent, for example, would not even come close to paying for salary and benefits for one government official, independent contractor, or lobbyist. Granted, the money given to any of these supports many other industries (transportation, tailors, restaurants, hotels sommeliers) but isn't it true that the money spent on patient care also supports others in the community (bus, JC Penney, Wendy's, Motel Six, 7-11)? In fact, either way, aren't we just recycling dollars through the system and stimulating the economy (except for those nasty multinational drug companies )? Patient care, like unemployment benefits, supports jobs and lifts the economy.

In fact, the more expensive health care can become, the more government officials, contractors, and lobbyists will be needed to deal with it. We can eventually spend our way to prosperity. Happy Birthday, ASCO.!! Looking forward to 50 more!!* Keep up the good work!!

Not at all out of the question. Of the seven founding members, Jane Wright died in 2013 at age 93, Arnoldus Goudsmit in 2005 at age 96, and Herman Freckman in 2009 at age 97.