ABCDE
HEALTH SCIENCE
tuesday, april 27, 2010
&
SCIENCE NEWS
Brain training
It seems that video games don’t make you smarter. Unless they’re very hard. E3
HOW & WHY
DIY energy Our bodies, our clothes, our daily activities can generate power. E3
URBAN JUNGLE
It’s all about the spin
The single-winged maple seed inspires a micro-aircraft. E6
What to ask
CONSUMER
REPORTS
Advice on finding the right hospital and the right surgeon for the right results. E2
QUESTIONS IN CANCER TREATMENT
War against cancer has more than one target
Decades of research reveal diversity in a disease once seen as a single ailment
by David Brown
Declaring a “war on cancer,” President Richard Nixon signed the National Can- cer Act on Dec. 23, 1971, in a White House room full of happy scientists and proud politicians. The bellicose metaphor implied that cancer was one enemy and that victory was possible. Nobody believes that any- more. It would have been no less naive if Nixon had declared a “war on bad gov- ernment” that day, ignoring the fact that there are a hundred ways to govern poorly and no single way to do it right. The quaintness of the idea of a “war on cancer” says a lot, in fact, about how much we’ve learned in the past 39 years. It’s true that in one sense cancer is still a single disease, defined then and now as a state of uncontrolled growth in cells. What’s different in 2010 is that sci- entists understand at the molecular lev- el dozens of different ways that cancer- ous cells achieve the state of uncon- trolled growth (with more being discovered every year). They know that the differences are sufficiently great that there will never be a singular “cure for cancer” — but that the differences may point the way toward lots of very good treatments. The deconstruction of “cancer” into its hundreds of varieties — each of which can be labeled by its own DNA mutation, chromosomal translocation, gene amplification or other defect — may be the biggest achievement of the war on cancer. It’s not just that leukemia, osteosarco- ma and breast cancer are different in the genetic defects underlying them. Each of those has subtypes with a somewhat different menu of defects that may affect how they respond to treatment. Even within the subtypes, some tumors are especially dependent on one defect or another for their bad behavior, even if
cancer continued on E4
How cancer begins
Five ways that the growth of cells goes awry. E4
BITTER PILL
A
TO SWALLOW
CHRISTINA KOCI HERNANDEZ FOR THE WASHINGTON POST
Fighting colon cancer, Jere Carpentier hoped to avoid intravenous chemotherapy. But her insurer refused to pay the higher price of oral drugs.
by Sandra G. Boodman
Kaiser Health News
When Jere Carpentier learned last year that she had advanced colon cancer — her third malignancy in a dozen years — she worried about spending hours in a clinic tethered to an intravenous line, enduring punishing chemo- therapy that would make her hair fall out. Her veins ruined by earlier treatments, Carpentier was elated when her oncologist said this time she could avoid needles and take a pill at home that would specifically target the cancer cells and spare her hair. “I let that be the thing that made this okay,” she recalled.
But the former human resources manager, who lives in San Jose, soon discovered that her insurer would not pay for the pill called Xeloda, which cost $4,000 per month, because a cheaper IV drug was available. So instead, she underwent surgery to implant a port in her chest through which she received 46-hour-long chemotherapy infusions, mostly at home. One night the device, which included a large needle that constrained her every move, sprang a leak and began emit- ting a shrill alarm, requiring a race to the emer- gency room. “It was the scariest thing that hap- pened to me,” Carpentier, now 60, recalled, “and I’d been through two cancers.” Scary and also unnecessary, in Carpentier’s view. “Surgery for the port and the ER visit alone
Gaps in insurance policies make oral drugs too pricey for some cancer patients
BIGSTOCKPHOTO
News from the annual cancer research conference. E6
Hoop dreams for survivors. E6
cost more than it would have for them to cover the damn pill,” she said. Like Carpentier, a growing number of patients are being denied access to newer oral chemo- therapy drugs or are required to shoulder hefty out-of-pocket costs, sometimes thousands of dol- lars a month, for cancer pills with annual price tags of more than $75,000. The reason is rooted in a reimbursement system that covers IV che- motherapy as a medical benefit but considers less-invasive oral chemotherapy to be part of a patient’s drug plan, which tends to be far less generous. Some plans cap drug benefits at $5,000 annually, which can amount to less than amonth’s supply of chemotherapy pills. The dis- parity is likely to affect increasing numbers of cancer patients, because 25 percent of 400 che- motherapy drugs in the development pipeline are oral. A recent report by the consulting firm Avalere found that oral cancer drugs, which account for about 10 percent of chemotherapy treatments nationwide, are typically placed in the most ex- pensive price tier in insurance and Medicare Part D drug plans, where out-of-pocket costs can reach 35 percent. People covered by Part D plans in 2010 must shell out $4,550 before they get through the coverage gap called the doughnut hole, after which they pay 5 percent.
drugs continued on E5
E
DM VA
When it’s helpful to tune out the truth
Denial can be deadly, but it usually gives people a chance to handle a medical crisis
by Ibby Caputo
Special to The Washington Post
A mother finds a lump in her breast while in the shower. It doesn’t hurt, and she has to get breakfast on the table and go to work, so she ignores it. A husband goes to the hospital to have
a total knee replacement. While there, he shows signs of alcohol withdrawal, but when the doctor asks his wife if he has a drinking problem, she says he hardly drinks at all. These are examples of denial, a com- mon defense mechanism that is often misunderstood, according to psychia- trists. In extreme cases, such as when a woman denies signs of breast cancer, the results can be deadly. But more often, a healthy dose of denial helps people en- dure and process a disturbing reality they or one of their loved ones are facing.
“From a psychiatric perspective, denial is the mind’s way of protecting the body and, actually, the mind, from some nox- ious truth,” said Terry Rabinowitz, med- ical director of the psychiatric consulta- tion service at Fletcher Allen Health Care in Burlington, Vt. “Think of the whole brain as comprising a bunch of different loudspeakers: Denial is the way for the brain or mind to turn down the volume on a certain set of speakers.” The concept of denial as a defense mechanism was introduced by Sigmund Freud, according to Hanoch Livneh, a psychologist who specializes in rehabili- tation at Portland State University in Or- egon. “Freud literally thought about it as
very pathological,” Livneh said, “some- thing that a normal person should not engage in.” In some cases, denial can indeed be
pathological. Lillie Shockney, administrative direc- tor of the Johns Hopkins Avon Founda- tion Breast Center and a two-time breast cancer survivor, said she sees such cases at least once a month. “A patient will come into the emergency room com-
plaining of severe pain,” she said, “not in the breast but in the spine or lungs, be- cause the disease is everywhere.” Shockney said that in these cases, as soon as the patient’s clothes come off, she can see the tumor eating through the breast tissue. She said such women will typically admit their breast has been in this condition for years, but when she asks if they thought it was cancer, they of- ten remain silent. “It doesn’t matter how much I see it,
I’m always stunned that someone can en- dure this,” Shockney said. It is a minority of patients who suffer in such a severe state of denial. Still, the majority of those with a life-threatening illness experience some form of denial, Shockney said. She can understand why. “Breast cancer remains the most feared disease of all women, no matter what age, ethnicity or race,” said Shock- ney. “From the time that a girl gets fitted for her first bra, she’s taught the value of having breasts. Society places a lot of im- portance on sexiness and womanhood.”
ROY SCOTT FOR THE WASHINGTON POST
denial continued on E5
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