February 2003

Survival Curse

By Michael J. Katin, MD

I've always been impressed at how treatment with radiation therapy has the ability to confer immortality on most of the participants in clinical trials. Usually there is a drop in survival or at least disease- free survival for 2 or 3 years and then nearly every curve levels off into infinity. Although it's not ethical to induce people to sign up for clinical trials by giving them money or free drugs, somehow it's OK to give them eternal life.

Whereas in Oncology this may not be able to be accomplished off protocol, it is much more remarkable what our colleagues in Cardiology have discovered.

According to Dr. Teri Manolio, director of the epidemiology and biometry programs at the National Heart, Lung, and Blood Institute, referring to the death rate from heart attacks: "That death rate is so low now that we're no longer able to track it. It's almost gone."

Yes, while you were at the most recent IMRT symposium, heart disease was all but eliminated from this country. The estimate is that 815,000 fewer people will die of heart disease this year than previously projected, not to mention 250,000 fewer will die of strokes. This is equivalent to five times the population of Akron, Ohio. This is a tremendous accomplishment, regardless of the need for having five more Akrons. Unfortunately this success story has long- term ramifications that may be detrimental to the health of all of us.

Despite all the criticism of the Medicare system, it turns out that it was designed accurately based on knowledge in the early 1960's. It was expected that the average beneficiary would be taking a dirt nap at about age 72-75. Medicare and, in fact, Social Security itself would be able to maintain solvency based on input of current workers and egress of the elderly.

At the same time, the medical profession was expected to push back the frontiers of knowledge (preferably in the favorable direction) and conquer diseases that had very nicely controlled the population for the past 5,000 years. In addition, nefarious prohibitionists have made it virtually impossible for tobacco to be consumed inside any public building and we may just now be seeing the population wave that may result from preventing a generation from indulging in burning things in their mouths.

This would all be wonderful except that we now have this backlog of people who, even without being on radiation oncology protocols, are sticking around far longer than expected. This has totally destroyed the projections for Medicare and Social Security, leading to political crises every 5 years or so that result in bipartisan commissions that fix the problem permanently, or at least until 5 years later. The next problem is that the prevailing attitude now is that if someone doesn't live to be 90 that one or all of his or her doctors screwed up. Dying of old age is no longer an option.

The final irony is now that we've been so successful in keeping people alive for so long, nobody wants to pay for this. It's almost like the story of the Pied Piper of Hamlin, who rid the town of rats and then nobody wanted to pay him. This is not to suggest loading up our offices with rats until the reimbursement/malpractice situation is settled (although not a bad idea) but we now have finally reached the situation of physicians protesting en masse in several states, something nobody would have very predicted (such as predicting abolishing smoking in bars). Physician slowdowns and even boycotts have been suggested. I'm not sure anybody would get frantic if radiation oncologists walked out for a week, but at least there would be a very vocal number of people in urinary retention that would be in distress by not having a urologist around.

I'm afraid that we are being penalized by our own success. Maybe we need a consensus that living to 75 is good enough for anybody (would you like some Soylent Green with that?) and in that case, the proper use of the tobacco settlement money would not be to give it to smoking cessation programs but to support production of tobacco--actually, that's already happened. Fortunately, the legal/political system will come through in the end. It's only a matter of time before defibrillators in stores are outlawed, just as soon as two or three people shock themselves acccidentally, and before we get those gas-guzzling Emergency Medical vehicles off the roads, once 30 mpg is mandated. That would help to get the death rate up again where it belongs, although the rats will still be with us.

email: mkatin@radiotherapy.com