August, 2014

Survival Instinct

By Michael J. Katin, MD

One of the first things that we should think about every day, and one of the last things anyone wants to think about, is our mortality. Specialists in radiation oncology are painfully aware that, no matter how good a job we do, the patient that was successfully treated in 1995 will probably not be around in 2035. This may also apply to orthopedists and urologists, but without the same poignancy.

As if to remind us of the ultimate futility of what we do, the New England Journal of Medicine recently published an article on "Where We Die," rather than an article on "Why Do We Have to Die." It would seem that the whole purpose of having had the New England Journal of Medicine published since 1812 was to find a way to keep people from dying. In any event it is interesting that there is an organization named the US Burden of Disease Collaborators (the meetings must be something to experience) which evaluates causes of disability and mortality, with the most recent calculations that from 1990 to 2000 life expectancy and healthy life expectancy (HALE) both increased, but that morbidity and chronic disability now account for nearly half the US health burden.

In the meantime, while researchers are doing their best to finally understand the mechanisms that promote and cause cancer, people are dying from exposure to pool chemicals and falling from ladders (the CDC has determined that falling from higher ladders results in more fatalities than falling from shorter ladders!!). Mortality and Morbidity Review has also calculated that 250,000 deaths per year in the United States could be prevented if people living in the Southern states (Alabama, Mississippi, Florida, Georgia, Kentucky, North Carolina, South Carolina, and Tennessee) had the same death rates from heart disease, cancer, chronic lower respiratory diseases, cerebrovascular disease, and "unintentional injuries" as did those living in North Dakota and Utah . The flaw is that these 250,000 people would not attain immortality and, in fact, would they want it if they were required to spend eternity in North Dakota or Utah? Eventually the reaper will be coming for them anyway, and they will contribute to the death rates, even if at a later year than if they had not given up partying in Biloxi.

Another problem is that, even if people don't have medical problems, they are capable of becoming statistics by their own efforts.

Suicide has become an increasingly common cause of death, with the not-surprising finding that lack of social integration is associated with a higher incidence (!!). It is very disheartening to find that there are at least 400 suicides of physicians each year in the United States, among persons who are supposed to be optimistic for the sake of their patients but become overwhelmed by the pressures of the profession. It is noted that the number of suicides of physicians or, at least, white male physicians, is 1.87 times the average, while the number of suicides of attorneys is 1.33 times the average and for electricians is 1.31 times. Maybe we're actually not exaggerating what we go through very day. Note that there are definitely certain professions that promote suicide in others.

The tragedy is that there are many ways to move on to the next level other than by dying of cancer. This makes all the more difficult the well-intentioned interest in survivorship. Traditionally, oncologists have followed patient for several years post-treatment, since we are more accustomed to look for signs of recurrence than the internist or family physician, and also to watch for any long-term sequelae of treatment. The American College of Radiology recommends following patients for five years. Now, however, there is increasing interest in survivorship as well as survival. The goal is to maximize a person's quality of life after definitive treatment was been completed. Ironically, improved quality of life alone does not necessarily qualify a therapeutic drug for approval by the FDA, but now seems to be important after the fact. Some aspects of survivorship management are very reasonable -- checking for osteoporosis in patients treated with hormonal therapy, for example -- but more and more problems are being identified to be studied, such as fatigue.

It has now been designated that part of the requirement for accreditation of every ACS-approved cancer program is for it to have a defined survivorship program. Hospitals are already concerned that this cannot be accomplished in adequate time for their next inspections and this has created a new stimulus for the economy. There already are specialists in survivorship ready to come into a cancer program and set up survivorship tracts for them. We had previously seen this for implementation of HIPAA and each time coding was significantly altered, not to mention when programs were mandated for domestic violence, risk management, snakebite, or HIV/AIDS education. This could also aid in the salvation of smaller cancer programs, in which follow-up of patients treated with chemotherapy and radiation therapy will be required and therefore able to be billed rather than referring these patients back to their primary physicians, as has been traditionally done. Programs can set up very specific protocols for office visits, diagnostic studies, and, most importantly, supportive ancillary programs that will benefit both physicians and patients.

Until, of course, lifetime bundling is implemented.