August 2002

Heart and Soul

By Michael J. Katin, MD

Back when we were in elementary school we had frequent opportunities to meet new playmates, but, unfortunately, those opportunities are now rare. Most of us in practice run into the same colleagues day after day, trying our best to make everybody happy and still get our jobs done. But now for the first time in years many of us have been thrust into the company of a group of specialists from whom we've been isolated for years: the cardiologists.

Although some of us have internal medicine backgrounds, for most radiation oncologists the only contact with cardiologists has been to deny that radiation therapy causes heart damage. We must have done a very good job of that, since now we're asked to use irradiation to treat heart disease. As the worm turns....

While we're happily and patiently waiting around to participate in coronary brachytherapy procedures, we can take the opportunity to recycle the repartee that we've perfected in years of working with urologists and neurosurgeons, but we should also be reflecting on the nature of our specialty and the broader implications of our impact on life and death. We have, after all, been brought together with a specialty with almost frightening parallels, sharing many of our features. Just as with people who are feeling fine who suddenly have an acute cardiac episode two days after having a normal EKG, we have people who don't understand how they can have cancer after having normal blood work done by their general practitioner earlier that month Many of the same factors that promote cancer - cigarette smoking, high fat diets, John Travolta movies - also contribute to heart disease. We used to agonize as to whether hormone replacement therapy was potentially harmful in terms of causing cancer, but still worthwhile in preventing heart disease--surprise! People with heart disease, as with those with cancer, may tend to be older, with other medical problems, and often with minimal social support at home, and we're often faced with dueling relatives arguing about the relative value of treating aggressively versus supportive care only. The difference usually is that when the loved one is actively infarcting and it's time to fish or get off the pot, nine times out of ten the decision is to go for broke, whereas in oncology there is rarely a precipitous event that requires a rapid decision.

The result is that we see patients and families still deciding whether to start radiation therapy and chemotherapy for locally advanced tumors once they've recovered from angioplasties and stenting. This is not to fault anyone's aggressiveness, but maybe we could achieve equal attention if we had a device that would make more noise as the tumor burden increased and would print out a squiggly line that would look worse as the proliferation index rose. A patient might be less likely to argue about a treatment time that would interfere with his golf schedule if there were a monitor beeping more rapidly with each additional log of cancer cells being born. It might mean that we would be doing emergency interventions several times a day, like the cardiologists, rather than several times a year, but wouldn't it be worth it?

Maybe or maybe not, but I would encourage that, just as we got Feng Shui from China and Antonio Banderas from Spain, there is always value in exploring the philosophy and tactics of our colleagues to try to maximize our value to society. So we should take advantage of this opportunity to interact with the cardiologists and learn their customs and beliefs. And when we've gained as much as possible, perhaps then we can find a way to bond with the most astute practitioners of them all: the chiropractors.

email: mkatin@radiotherapy.com