Wednesday, October 3, 2007

Chemo Missed Again, Plus Lessons Learned

I went for my weekly chemo treatment today but my white blood cell count was once again too low, so I just got a shot of Neupogen to boost my white blood cells. I’ll go back tomorrow to see if my counts are up enough for chemo.

I had a long conversation with my oncologist – the most satisfactory one I’ve had so far, in terms of getting the information I wanted.

I asked her why my treatment in Sydney was so different from what I was getting in Singapore, specifically the dosage of the chemo, as well as the number of side effect drugs.

The conclusion was what I’d said before – that in Singapore, they take a more pre-emptive approach and overmedicate to prevent any possible side effects that might come up, whereas in Australia, they wait to see if there are any side effects before giving medication for them.

But my oncologist elaborated in much more detail the reasoning behind her decision to pre-medicate so that I’m aware of her thinking process and can make more informed decisions. Better communication is all I needed.

It seems my doctor follows the American approach in aggressively eliminating even the slightest risk of allergic reactions to the chemo or other side effects. She was giving me five drugs for nausea and two drugs for potential allergic reactions to Herceptin. I’ve had two doses of chemo now without these side effect drugs and I’m fine. She said allergic reactions can build up over time, as in the case of one of her patients who was fine on Herceptin for the first several doses, then developed a strong allergic reaction and was unable to breathe. I suppose that might be a minimal risk, but I can see why a doctor wouldn’t want to take such a risk. That’s especially the case in the U.S., where malpractice suits are quite common. So that explains why she had me on so many side effect drugs.

In Australia and Europe, it seems they’re much more cost conscious because they have national health systems. So doctors and hospitals are encouraged to keep costs down by NOT prescribing drugs until they become necessary. If I’m in the 95% that do NOT have any side effects, then I’m getting all these additional drugs unnecessarily, at greater cost to me (but not the national health system). But we can’t know whether or not I’m going to have a side effect until I actually have it. The problem is that in some cases, by the time a patient exhibits a side effect, it’s too late to do anything about it. There’s the dilemma.

I’ve decided to take the middle ground between the two approaches and get just a few of the side effect drugs. If I later develop side effects, I’ll have no one but myself to blame.

I’ve also learned that some of the reasoning behind my doctor’s approach to treatment comes from very recent and less publicized studies that the Australian doctors are either unaware of or are choosing to ignore. Opinions are so varied among doctors, hospitals, and countries about which approach to take that there’s no absolute correctness to any one approach. And many drug treatment protocols are based on just a handful of studies with just a handful of test patients. Still more frightening… some are based on pure guesswork, with no concrete scientific evidence at all.

My doctor told me about one lung cancer drug that has been withdrawn from the European market because it has shown no response in the patients tested. But among Asian patients, the results have been very good. Why does this drug work in Asians but not in Caucasians? Is anyone studying this? Probably not. Meanwhile, doctors in Asia are prescribing a drug that has been taken off the market in Europe. And Asian patients in Europe might not be getting a drug that could help them. Very complicated.

So it seems there’s no right or wrong in this. The Australians have their methods and reasoning and so does my doctor. I found the Australians more convincing because they were more communicative and articulate. But now that my doctor has provided more information to explain her approach, I find myself landing somewhere in the middle.

I’ll probably need to do a chemo session in the U.S. when we’re there during the Christmas holidays. Then I’ll have one more country to add to my collection. Maybe I should plan a chemo trip to Europe as well. I wonder if I can apply for a research grant for comparative chemo by country using me as the subject…

1 comment:

Alison said...

And I'm sure if you went back to Australia and said, "Hey, if you don't give me these side-effect drugs I might suffer terribly because it will be too late when they appear," they could easily have a rational explanation for how they made the decision and would deal with it. There are layers and layers and layers to this thing. But at the center of it, as you say, is what doctors are, or aren't, telling patients.