Sunday, July 8, 2012

How  We Do Harm - A Doctor Breaks Rank About Being Sick in America

This book was written by Dr. Otis Webb Brawley, Chief Medical and Scientific Officer of the American Cancer Society as well as a professor of hematology, oncology, medicine and epidemiology at Emory University in Atlanta.  Overall Dr. Brawley is an advocate for evidence based medicine, as I believe every doctor should be.

How We Do Harm is one of the better books I have read on how cancer is treated in the US.  It covers some of the issues with overtreatment, the relationship between doctors and pharmaceutical companies as well as how different people get treated depending on their financial situation and insurance coverage.  The book may overlap with The Emperor of All Maladies and Overdiagnosed.  Nonetheless, it will give the reader a needed dose of skepticism as well as an incentive to be your own advocate.  Caveat Emptor!

Some of his terminology is funny in a sad way including:

Wallet Biopsy:  An analysis of the patient’s financial durability.  This is particularly relevant for cancer patients dealing with the high costs of their treatment.

GOMER:  Get out of my emergency room .This one came out of a book named The House of God that refers to “a person who has lost – often through age-what goes into being a human being.  A GOMER could be demented residents of nursing homes whose bodies wouldn’t die”.  Another category of GOMER is:

“LOL in NAD:  Little old lady in no apparent distress.  This refers to an elderly woman, perhaps a widow, who comes into the emergency room probably needing some psychiatric help - or more, likely, some simple human companionship".

I’m including these terms because I find them amusing. They may also help give the reader a flavor of the cynicism and humanity involved in being a doctor. 

A decent portion of the book is spent on pharmaceutical companies and their inherent conflicts of interests with doctors.  Specific examples are Procrit (Johnson & Johnson) and Aramesp (Amgen) that were used to build up hemoglobin in patients undergoing or subsequent to chemotherapy.  Procrit was approved by the FDA in 1993 based on a very small study of only131 patients.  It was introduced first and featured television advertising to patients talking about getting their strength back after chemotherapy.  This culminated with a Super Bowl ad in 2003
Amgen responded with a competing drug (Aramesp) in the early 2000’s and struck a deal with oncology practices to buy the drug in bulk, offering rebates of up to 20% of the cost, depending on prescription volume.  By 2006, sales of the drug were $4.85 billion in the US.   Two larger randomized studies showed the placebo group lived longer than those being treated with these drugs!  The second trial was stopped due to this fact.   After 13 years on the market, the evidence showed that patients on these drugs had higher incidences of heart attack and stroke. The two drugs also caused “tumor promotion”, meaning they caused tumors to grow.  The FDA put severe restrictions on the use of both Aramesp and Procrit in 2010, but not before making many oncologists rich.

Another FDA approval was for a combination of Gemzar and Tarceva for use in pancreatic cancer because it increased median survival by a grand total of fourteen days!

This anecdote hit close to home for me: It is about doctors stricken with post traumatic stress disorder (PTSD) from treating so many patients who will die.  “Many of my colleagues have learned to ward off PTSD by becoming assholes”.

Another case depicted a patient who demanded treatment despite protocols against it.  The patient had 3 doctors, including Dr. Brawley, advise against chemotherapy.  The primary doctor treating the patient said “People like that get what they want.  If I hadn’t done it, someone else would have”.

At the other extreme is the family who wants to keep the patient alive when there is no hope for a cure or any quality of life.  The author touches on this and denotes statistics that seem to be all over the news these days such as:  “24% of Medicare spending and 15% of all health spending is in the last year of a patient’s life”.  This is unsustainable, causes unnecessary suffering and keeps others from getting decent healthcare. 

This was a very readable, enlightening yet disturbing book. I would highly recommend it to anyone with cancer or a chronic disease.