Intense Public Debate

A more than usually absurd post from me. I'm sorry; I couldn't resist.

Who could have guessed that after "intense public debate" [dead news link], such a bizarre solution could win acceptance: "After intense public debate, the [goose extermination] plan was dropped in favor of non-lethal alternatives: including deployment of a border collie in a life jacket, yapping from aboard a kayak"

[dead photo link]

I wonder which ideas never made it off the flip-chart.


$25,000 Per Month

I'm going to go off on a bit of a rant here on a subject I have not broached on this blog but encounter nearly every day in my practice: the rapidly escalating costs of medical care, cancer care in particular.

At this year's annual scientific meeting for the American Society of Clinical Oncology (ASCO), investigators reported the findings of a trial conducted in lung cancer patients with incurable disease. Here's the snappy title of their report: Randomized phase II/III Trial of paclitaxel (P) plus carboplatin (C) with or without bevacizumab (NSC # 704865) in patients with advanced non-squamous non-small cell lung cancer (NSCLC): An Eastern Cooperative Oncology Group (ECOG) Trial - E4599. The investigators compared the outcomes of treating patients with combination chemotherapy using paclitaxel and carboplatin to those of patients also receiving bevacizumab. The earth-shattering conclusion of the study: "The addition of B to PC in pts with NSCLC (non-squamous) provides a statistically & clinically significant survival advantage with tolerable toxicity. PCB [an unfortunate acronym] is ECOG's new treatment standard in this patient population."

How much advantage did treating with bevacizumab confer? On average, patients went an additional 8 weeks without their disease progressing, and survived 10 weeks longer than those receiving chemotherapy alone. Well, I suppose that's progress.

In an editorial regarding the costs of bevacizumab therapy appearing in the American Journal of Health System Pharmacists by Dr Jill Kolesar, the author notes that adding bevacizumab to chemotherapy increases the risk of vascular complications by a small amount. Perhaps more significantly, bevacizumab costs USD$50,000 for a typical course of treatment.

Does it make sense for a cash-strapped health care system to dispense such an expensive drug for a survival benefit that is measured in weeks? ECOG, a group of cancer treatment facilities in the Northeastern US, has adopted this drug as its standard of care. In the US, once the drug has obtained regulatory approval for its use following a demonstration of its relative safety and effectiveness, it can be prescribed with impunity as long as a payer can be found. For the latest innovations on the market these payers are typically private health insurers or individuals themselves .

The situation in Canada is different. The payer is the government agency overseeing cancer care. Before an anti-cancer drug can be given in this system, it must not only satisfy similar federal regulatory requirements as in the US, it must also be added to the provincial drug formualry if its cost is to be covered. This usually follows an evaluation of its efficacy, toxicity, and clinical and fiscal impact. On some occasions, third party payers can be found for patients who are veterans, in law enforcement, covered by Workers' Compensation, or the like. For the most part, there are no private insurers to foot the bill.

This is probably a good thing from a public health perspective. The third party payers who were pressured in the mid-1990's to cover the costs of high-dose chemotherapy and bone marrow transplantation for breast cancer wound up doing more harm than good. Such a treatment approach has been infamously discredited, with one of the main proponents of the approach--Dr Werner Bezwoda--charged with fraud and dismissed ignominiously. By being late adopters of new treatments, Canadians benefit from a longer experience and more accurate picture of the potential pitfalls of the new treatment. In the meantime, patients are sometimes deprived of the benefits of those treatments.

It is a delicate balance. As a physician, I see my role as an advocate for my patient, seeking to optimize their care. If I am constrained by wait times to tests or operations, the availability of appropriate expertise in my region, the availaility of a drug, etc, then at least I have sought to obtain these things for my patient. Should the system fall short of delivering what I seek, I have to accept these limits or petition to alter them by admittedly byzantine channels.

Practicing in this environment makes physicians in Canada more sanguine than their US counterparts. We cannot gleefully embrace the latest and greatest devices and drugs simply because they exist. We must investigate their effectiveness and pitfalls ourselves, or otherwise prove their advantage before they can routinely be adopted.


Blast From The Past: Deflating Lucas

While cleaning out my mailbox I discovered an old message from April, 2002, that is of interest today. It addresses a Salon.com article criticizing the overblown mythos of the Star Wars saga, subtly titled "Galactic Gasbag". Here's my reply to the friend who pointed the article out to me:

Even my five-year-old son finds interviews with Lucas tiresome. I agree that his ingenuine inflation of the Star Wars mythos is as overwrought as when the camera lingered on the death of a single ewok at the Battle of Endor while stormtroopers died in scores. However, not all the points of the salon article are valid. I think that the archetypal story arc that Campbell describes *is* a pervasive one, *does* reflect some aspects of the Star Wars story arc, and is one that repeats in nearly every heroic epic, whether the writer was conscious of the fact or not:

1. The Call to Adventure
2. Refusal of the Call
3. Supernatural Aid
4. The Crossing of the First Threshold
5. The Belly of the Whale

1. The Road of Trials
2. The Meeting with the Goddess
3. Woman as the Temptress
4. Atonement with the Father
5. Apotheosis
6. The Ultimate Boon

1. Refusal of the Return
2. The Magic Flight
3. Rescue from Without
4. The Crossing of the Return Threshold
5. Master of the Two Worlds
6. Freedom to Live

The pattern repeats in myths, literature, pulp, and film because it offers a compelling heroic journey. And while the trash-compactor-as-whale analogy is admittedly ludicrous, I think it would be erroneous to try to fit every story to every component of the pattern.

Lucas is a huckster, and his high-brow claims don't delude me. Ths [sic] might surprise you: I can't wait until May 2005 when Anakin falls, the Jedi are exterminated, the saga is over, the DVDs are all bought, the LEGO kits are all on the shelf, and nothing more will be heard from the Skywalker Ranch but a faint chuckle and riffling of bills as George Lucas counts his great wads of cash.