Or, to put it another way, if you were the one who had metastatic cancer—or, for that matter, a similarly advanced case of paperless emphysema or congestive heart failure—what would you want your doctors to do? The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the countrys long-term solvency, and the terminally ill account for a lot. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit. Spending on a disease like cancer tends to follow a particular pattern. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off. Medical spending for a breast-cancer survivor, for instance, averaged an estimated fifty-four thousand dollars in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy. For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the end—to an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer.
She was upbeat by nature, and she managed to maintain her optimism. Little by little, however, she grew sicker—increasingly exhausted and short of breath. By november, she didnt have the wind to walk the length of the hallway from the parking garage to marcouxs office; Rich had to push her in a wheelchair. A few days before Thanksgiving, she had another ct scan, which showed that the pemetrexed—her third drug regimen—wasnt working, either. The lung cancer had spread: from the left chest to the right; to the liver; to the lining of her abdomen; and to her spine. Time was running out. This is the moment in Saras story that poses a fundamental question for everyone living in the era of modern medicine: What do we want Sara and her doctors to do now?
The Internet Classics Archive apology by Plato
But the paclitaxel triggered an extreme, nearly overwhelming allergic response, so he switched her to a regimen of carboplatin plus gemcitabine. Response rates, he said, were still very good for patients resume on this therapy. She spent the remainder of the summer at home, with vivian and her husband and her parents, who had moved in to help. She loved being a mother. Between chemotherapy cycles, she began trying to get her life back. Then, in October, a ct scan showed that the tumor deposits in her left lung and chest and lymph nodes had grown substantially.
The chemotherapy had failed. She was switched to a drug called pemetrexed. Studies found that it could produce markedly longer survival in some patients. In reality, however, only a small percentage of patients gained very much. On average, the drug extended survival by only two months—from eleven months to thirteen months—and that was in patients who, unlike sara, had responded to first-line chemotherapy. She worked hard to take the setbacks and side effects in stride.
Even with chemotherapy, the median survival is about a year. But it seemed harsh and pointless to confront Sara and Rich with this now. Vivian was in a bassinet by the bed. They were working hard to be optimistic. As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics.
They wanted to focus on aggressively managing this diagnosis. Sara was started on the tarceva, which produced an itchy, acne-like facial rash and numbing tiredness. She also underwent a surgical procedure to drain the fluid around her lung; when the fluid kept coming back, a thoracic surgeon eventually placed a small, permanent tube in her chest, which she could drain whenever fluid accumulated and interfered with her breathing. Three weeks after the delivery, she was admitted to the hospital with severe shortness of breath from a pulmonary embolism—a blood clot in an artery to the lungs, which is dangerous but not uncommon in cancer patients. She was started on a blood thinner. Then test results showed that her tumor cells did not have the mutation that Tarceva targets. When Marcoux told Sara that the drug wasnt going to work, she had an almost violent physical reaction to the news, bolting to the bathroom in mid-discussion with a sudden bout of diarrhea. Marcoux recommended a different, more standard chemotherapy, with two drugs called carboplatin and paclitaxel.
My take: If you hear, god speak audibly, you (usually) arent
Nothing she had report done had brought the this. More than fifteen per cent of lung cancers—more than people realize—occur in non-smokers. Hers was advanced, having metastasized to multiple lymph nodes in her chest and its lining. The cancer was inoperable. But there were chemotherapy options, notably a relatively new drug called Tarceva, which targets a gene mutation commonly found in lung cancers of female non-smokers. Eighty-five per cent respond to this drug, and, marcoux said, some of these responses can be long-term. Words like respond and long-term provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage.
Were having a baby. And were going to enjoy our baby. On tuesday, at 8:55. M., vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her mom, and intel she was perfectly healthy. The next day, sara underwent blood tests and body scans. Paul Marcoux, an oncologist, met with her and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had started in her left lung.
think about. So sara and I looked at each other, rich recalled, and we said, we dont have cancer on tuesday. Its a cancer-free day.
Her mother, who had lost her best friend to lung cancer, began crying. The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For the moment, though, sara and her husband, rich, sat plan by themselves on a quiet terrace off the labor floor. It was a warm Monday in June, 2007. She took richs hands, and they tried to absorb what they had heard. She had never smoked, or lived with anyone who had. The diagnosis was bewildering.
Can t say - paul Graham
Modern medicine is good at staving off death with aggressive interventions—and bad at knowing when to focus, instead, on improving the paperless days that terminal patients have left. Photograph by Phillip Toledano, birthday balloon, from days with my father (2008). Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didnt get into the prognosis—she would bring in an oncologist for that—but Sara was stunned.