There's an article in the today's (Sunday) New York Times "Cancer Patients, Lost in a Maze of Uneven Care" that hit home to me. It lays out the difficulty for patients in finding the right doctors and the correct treatment when you have cancer.

The article highlights some consensus statements on general principles of cancer treatment by the National Comprehensive Center Network. This information is useful to get your feet wet on learning about cancer treatment and can be found here. Several specialists at super-tertiary cancer programs comment on the "shocking" lack of standardized care in many instances in how common cancers are treated. Implicit in some of these statements is the notion that you have to go to some super-duper place like Memorial Sloan-Kettering (MSK) in NYC or MD-Anderson in Houston,TX for cancer treatment.

This is an absolutely ridiculous idea to me in most instances, except for certain surgical procedures which are only done commonly by a handful of super tertiary specialists. Post-operative morbidity & mortality for some of these procedures seems to directly correlate with volume, and volume tends to accumulate in small numbers of hands. However, I work commonly with community surgeons (a number of whom trained at places like MSK) who do higher numbers of these cases then the local super sized University-based teaching hospital.

Cancers of the liver, stomach, esophagus, pancreas, brain, and advanced head and neck tumors are the ones where I think you may be better off finding one of these specialists. For breast or colon cancer it's asinine to suggest you get better surgical treatment. For chemotherapy or radiation therapy the same "cookbook" for standard treatment exists whether you're in Manhattan or Mobile,AL and you shouldn't need to travel for it. Certain investigational trials (which again aren't standard and weren't the focus of the NYT article, may require you to go to regional cancer centers)

There's a patient in the article with aggressive stage IV colon cancer with liver spread who was (appropriately I think) counseled on the futility of extra aggressive chemotherapy and suggested a palliative regimen. She's used as an example of "under treatment" when she visits a referral center in Seattle that later used more then twenty cycles of chemotherapy to likely extend her life by less then a year and subsequently went to Johns Hopkins in Baltimore for what sounds like an ill-advised radical liver resection. Ironically my little brother is actually an oncology fellow at Johns Hopkins.

Even more ironic, is that last week I authored a section about surgical treatment of liver metastasis in the colon cancer entry on Wikipedia. Small world, eh?

No mention is made of exactly how gruelling this kind of therapy is, nor is there any perspective of the costs of treatment to the system. This was over $400,000 of dollars more expensive then what was recommended by her first oncologist. In an aside to the debate over "Sicko" and government health systems, you can bet that this treatment would not be subsidized by universal health care systems in most of the rest of the world.

As part of the food-chain of the oncology system, most often for breast and skin cancer, I see this all the time. One of the frustrations of breast reconstruction is trying to read the tea leaves about what kind of chemotherapy, radiation, and mastectomy a patient will receive. Variations in any of these can dramatically affect the quality of reconstruction, which is more of a tertiary concern from an oncology perspective but is often the most important from the patients perspective.

I'm just a "dumb skin doctor" these days but in scanning the NCCN recommendations on breast cancer treatment, I found a number of statements I thought either wrong, misleading, or at least up for debate. In particular they seem to be rather eager to irradiate people (for little or no benefit) and still wedded to the idea of "lumpectomy for all". When younger women, whom generally have aggressive tumor characteristics, are made to understand that (at approaching two decades follow up) between 15-19% of people treated with lumpectomy and radiation may have local recurrence of their invasive breast cancer, the rationale and enthusiasm for breast conservation diminishes sharply.

Plastic surgeons are particularly tuned in to the problems of radiation as we inherit them for reconstruction. By and large, if you considering a lumpectomy with radiation, you do not want to ask a Plastic Surgeon's opinion of it as we disproportionately see the complications. That's a post for another day.

Rob

Michael Moore was on MSNBC's Hardball with Chris Mathews Monday and was his usual obnoxious (I ironically mean that in a good way with Mr. Moore) self, promoting his documentary, "Sicko" and the idea that Socialized medical care is a panacea.


At least he had the honesty to admit that a number of Americans will receive "worse" care (at least in terms of convenient access) then they currently enjoy. The philosophical arguments about healthcare and how much it's a right versus a commodity is an important one to have, and, "Sicko" has galvanized the debate. A perfect storm exists for progress on this issue in that big business, labor unions, and the zeitgeist of the country all support a universal system in the abstract sense. The devil's in the details and $$$$ involved.

While federal systems enjoy popular support in other countries, it's not all milk & honey. It's ironic that as many as 15-20% of citizens are estimated to seek care outside the government run systems in western Europe that are lionized by activists. The system Moore champions (like only Canada, Cuba, & North Korea's - an unlikely triad) would not tolerate any private sector competition for care delivery or services as it would undercut the federal system and prove more popular with many patients with financial wherewithal. Write this down, THIS WILL NEVER BE ACCEPTED IN THE UNITED STATES, so I don't think that system is worth discussing in depth.

There's a real alternate take on the Canadian system celebrated by Mr. Moore in "Sicko" by the underground film hit "Dead Meat" which features Canadians frustrations with the reality of long waits for imaging studies, orthopedic surgery, cancer treatments, and even cardiac surgery. It's ironic in Canada that you can actually buy health insurance for your pet, but not yourself or child.

Anecdotes are a poor way to determine public policy, but it goes to show that you just don't get something for nothing.

Click on the screen below to watch "Dead Meat"




At least a few times weekly I get asked whether or not someone will have a scar after a certain procedure. People are sometimes under misconceptions about how exactly Plastic Surgery works. Anything you cut, burn, or excise scars. The quality depends upon a number of factors including





  1. location - certain areas don't scar as well as others (behind the ear, the medial-lower breast, the armpit, the scalp)


  2. tension - more tension equals wider scars. This plays a factor in the areas listed under location. Incisions across areas with lots of motion (the knee, wrist, & shoulder) all tend to be wide.


  3. technique - Plastic Surgeons didn't invent good surgical technique and gentle tissue handling habits, but we tend to pay more attention to it.


  4. genetic predisposition - sometimes it's your parent's fault. A number of people display profound inflammatory responses with exaggerated scarring from anything. I make a point of discussing this with Asian and African-American women (who have higher rates of hypertrophic or keloid scarring) when discussing breast surgery.


  5. medical commodities - diabetics, obese patients, those with arterial disease, and gastric bypass patients all have baseline wound healing problems to some degree.


  6. age - the inflammatory response of normal healing varies with age. You can do experimental surgery in utero and get essentially scarless healing of a fetus. However the response in children and teens to injury can be exaggerated scars as their immune systems tend to be "peaking" during those years. Alternatively, you can do things to the face of 70-90 year olds that would disfigure younger patients and often not even find a scar.

Rob

Lest we forget where BOTOX comes from....

Several recent scares with Boutulism food poisoning should be a reason to reexamine where BOTOX comes from. At right is a high magnification image of botulism spores.

Castleberry's Food Co. of Augusta,GA recalled more than 90 types of canned chili, beef stew, corned beef hash and other meat products. Cans of chili sauce made by the company were found in the homes of an Indiana couple and two children in Texas who had been hospitalized with botulism toxicity. All four are expected to survive. Botulism can be lethal by paralyzing the repiratory muscles when ingested in quantity.

Boulinum toxin is the product of the bacteria, Clostridium botulinum. A layman's description of how botulinum toxin works courtesy of Wikipedia:

BOTOX (the cosmetic) came from the observations of an opthamologist who was treating a patient for blepharospasm (BOTOX's initial clinical use) and noticed his patient's wrinkles got better in his forehead. Likewise BOTOX's use for treating migraines came from the observation of a Plastic Surgeron who was treating wrinkles (both surgically & with BOTOX) and kept being told his patients headache's were getting better. BOTOX is now used from everything to hyperhidrosis (extra sweating) in the palm or armpit, esophageal spasm, anal fissures, constipation, and 1001 other novel applications.

A competitor preparation of botulinum toxin called Reloxin is due to be introduced to the US later this year and will finally give some competition to lower the price for these kinds of medicines.

Instant Karma meet one John O'Quinn, attorney-at-law of Houston, TX. Mr. O'Quinn is best know as the shake-down artist who fleeced several implant manufacturers in the 1990's for a billion dollars +(USD) over the since dismissed claims of diseases allegedly caused by silicone breast implants. O'Quinn's total attorney fees while his firm represented the plaintiffs was over $260 million.


It seems like a only quarter of a billion dollars was not enough for counselor O'Quinn, who was stung Friday with a judgement for (with interest) nearly $60 million dollars for defrauding his clients with irregular (and undeclared) attorney fees as well as bogus and phantom expense reports.

O'Quinn was a particularly nauseating player in the late "silicone crisis" phantom menace that was driven to ridiculous heights by O'Quinn et. al. To this day his breezy attitude toward the truth (or as best we understand the truth on breast implants) represents the worst stereotypes of the American trial lawyer., ie. "Never let truth get in the way of a class action payday".

In lawsuits against the since bankrupted Dow Corning, O'Quinn made ridiculous leaps of logic during arguments with an over the top closing statement urging jurors to ignore the science and instead rely on “common sense, circumstantial evidence,” and post hoc ergo propter hoc (If "x" happened it must be from "y") reasoning. America, being the home of jackpot justice, rewarded these lawyers with staggering wealth.

From the Houston Chronicle:
An arbitration panel Thursday ordered O'Quinn to pay at least $35.7 million to more than 3,000 former breast implant litigation clients for collecting improper fees. The award includes $10.7 million in improper fees and a $25 million
penalty, the panel said.

The 3,000-plus women joined in a 1999 lawsuit claiming O'Quinn took funds from their settlements for group charges they had not agreed to pay. One of their lawyers estimated that with interest and lawyer fees, O'Quinn could pay up to $60 million out of his estimated $263.4 million in fees from the implant litigation.


$60 million, huh. Couldn't happen to a nicer guy.

Rob


A $25,000 tax deduction claimed by a Boston man in 2001 for Plastic Surgery to feminize him has been disallowed and is being played out in Federal Tax Court next week. Rhiannon O'Donnabhain is suing the IRS in a case advocates for the transgendered are hoping will force the government to treat sex-change surgery the same as appendectomies, heart bypasses and other deductible medical procedures.

Activists argue that because gender-identity disorder is a recognized disorder in the medical literature, the costs are therefore legitimate medical deductions. This is a patently ridiculous assertion, which looks even more ridiculous in the context of a health care system that is going bankrupt.


Most reasonable people are going to be sympathetic to the psychopathology of transgender individuals, but asking them to subsidize their cosmetic surgery (it is not reconstructive surgery) to self-actualize their body image/identity issue is DOA. The IRS says cosmetic surgery or similar procedures are deductible only when they are needed to improve a congenital abnormality, an accident or trauma, or a disfiguring disease. I wrote a post on the history of plastic surgery and tax deductions last fall here

As many as 2,000 sex change operations are done annually in the United States which can include components such as mastectomy (removal of the breast), feminizing of the face, castration, turning a penis into something resembling female genitalia, and everything in between.


If you want to see some very interesting (but graphic) photos of the surgery for this you can go here and scroll down. The creativity of these kinds of procedures and the skill of the surgeons is really without question. Unfortunately, the number of doctors who do these is dwindling as it's kind of been marginalized as a real small niche within both Plastic Surgery and Urology. Ironically, there's real good money in this area because there's so few doing it and they can charge premium fees for their surgical services. In an era where we're making tough decisions re. what we can and can't afford with health care, I have no problem expecting people to finance these operations themselves.


Rob

A break from serious topics today for some free swag!

There's a great single available for free download courtesy of Salon.com from the indie-rock duo Tegan & Sara. Unfortunately, Salon.com is getting rid of their column, Audiofile, which is a great sources of free music.

Download the uber-catchy "Back in Your Head" here

also check out free downloads from


Rob

I'm really not trying to beat a dead horse on this theme, but there is an absolute stunning case developing in Arizona re. the actions of an Internist who reinvented himself as a cosmetic surgeon.





A massage therapist performed a liposuction procedure in which a woman died. A homeopathic physician who was denied a medical doctor's license by the state board did another procedure in which a patient died.Others who performed cosmetic surgery did not have formal medical training,including a bookkeeper and a former restaurant owner. The procedures were all conducted in one Anthem doctor's office, according to a report by the Arizona Medical Board on a case that has left three people dead since December.

After two patients suffered cardiac arrest and died during liposuction procedures in December and April, Dr. Peter James Normann was ordered by the state in May to stop performing surgeries and administering sedation drugs.Less than two months after the order was issued, Gary Page, a homeopathic doctor whom Normann had contracted with to perform medical procedures, did a liposuction on a 53-year-old woman in Normann's office (who later died from either oversedation or lidocaine toxicity I suspect)

Dr. Normann's Web site indicates he is an experienced cosmetic surgeon. But his medical certification was in internal medicine, and his specialty was listed as emergency medicine, according to state medical board records.


This case is absolutely nauseating to me to imagine someone like that is practicing medicine. Three deaths from liposuction in 6 months is staggering. Dr. Normann is certainly not representative of all wanna-be Plastic Surgeons, but he does highlight the seriousness of traditional plastic surgery procedures perceived to be "simple" like liposuction or breast augmentation. I cannot believe that there isn't going to be some real backlash in Arizona over this, and maybe there should be.

This case represents the second well-publicized episode within a year of office-based surgery deaths in AZ (see this post "Office based surgery, is this going o be legislated away?" from last February) the last involving the death of a prominent attorney in an accredited office surgery suite from anesthesia complications. It only takes the energy of a single state representative to put signifigant restrictions on office surgery into play in the legislature.


MyFreeImplants.com just completed a promotion at the Erotica-LA convention, a sexuality and lifestyle exposition, which culminated with its second annual free boob job giveaway. Much like the contest in Florida we discussed in the April post here, " Does it make sense for an E.R. Doctor to do your breast surgery?", the "plastic surgeon" doing the breast augmentation is also in fact not even a plastic surgeon at all. (I guess things are "improving" in that unlike the former episode, this doctor at least trained partially in some kind of surgical residency)

The surgeon, "Dr. S", in this instance is not a Plastic Surgeon by training and apparently is not even board-certified by any board recognized by the American Board of Medical Specialties (ABMS) . You'd have a hard time knowing that by the somewhat deceptive way many physicians like this market their practice (I don't mean that perjoratively directed at "Dr. S." BTW) . When looking on the Internet or thru the Yellow Pages, these doctors will call themselves Plastic Surgeons or the catch-all "cosmetic surgeon", and pay to have themselves listed in directories of real Plastic Surgery physicians.

If you see someone with a lot of "board certifications" next to their name but not The American Board of Surgery/Plastic Surgery (ABPS) or membership in the Amer. Society of Plastic Surgeons (ASPS), they aren't a Plastic Surgeon in most instances. Most egregious are ones like the obnoxious American Academy of Cosmetic Surgery which were created out of thin air and are not recognized by the ABPS or ABMS (the gold-standard organization for credentialing physicians) and do nothing more then to confuse patients.

Fat grafting the breast is a controversial topic. A biotech firm claims to have come up with a feasible model for immediate reconstruction of lumpectomy defects involving injecting stem cells from fatty liposuction aspirate of a patient's abdomen. The process from Cytori Therapeutics is called Celution™ . The San Diego Times-Union featured this a few months ago here.



From Forbes Magazine:






In the technique, adipose (fat) tissue is taken from the patient, using a minor liposuction-like procedure. The tissue is then placed into the Celution system, and processing begins. An hour or so later, a dose of regenerative cells is delivered back to the patient, injected in the breast. Fat tissue contains many types of cells, (Thomas) Baker said, but the stem cells and regenerative cells are the "stars" that make the reconstruction possible










Now it's unwise to blow off the wisdom of a guy like Dr. Tom Baker, the Miami plastic surgeon of historic contributions to our field (particularly in face-lift surgery & by virtue of him literally inventing the first effective chemical peel in the late 1950's), but I have some doubts about this. It's going to take at least 10-15 years of incredibly close follow-up to make any kind of conclusion about the effect of stem cell fat-grafting a breast with cancer. The premise of injecting pleuripotent (cells which can "turn" into other cells in layman's terms) stem cells into an organ that's cancer-prone sets off lots of alarm bells. Like "regular" fat grafts, you presumably are going to create mammogram artifacts, which is something you have to approach carefully in someone with a personal history of breast cancer. The American Society of Plastic Surgeons has come out on the record in 2006 against fat grafting of the breast for just such concerns.

Also, on a more practical level, who is going to pay for this?

Most lumpectomy sites don't require any treatment for starters. As I understand this kind of stem-cell "transplant", it takes several hours to harvest and prepare the cells which is expensive time in an O.R. In an era where reimbursement for surgeons performing breast cancer reconstruction has fallen nearly 75-80% since 1990, I cannot imagine this being adopted by Medicare or other 3rd party insurance payers and if they do it will not be economically feasible to perform it. This is what happened to surgery using your own tissues (ie. TRAM flaps), the congress mandated coverage for breast cancer reconstruction in legislation, but Medicare and insurers subsequently made it difficult to earn a living doing it, particularly in the case of muscle flaps or microsurgical reconstructions.


The stem-cell potential of this kind of technology seems to have much more practical potential in areas like ischemic heart disease and neurodegenerative processes IMO then reconstructive Plastic Surgery. If the price comes down, use for cosmetic injections in the face might also be an interesting indication.


Book review "Straight Talk About Cosmetic Surgery."



I was asked by the Yale University Press to review an upcoming book on Plastic Surgery, "Straight Talk on Cosmetic Surgery" by New Jersey Plastic Surgeon, Dr. Arthur Perry. This book will be on sale in two weeks for $18 and be available from Yale Press as well as Amazon.com, etc.

I don't know Dr. Perry, but I can tell he'd be fun to sit and have drinks with. His book was genuinely interesting and it's written in a really down-to-earth and very funny tone. It is remarkably comprehensive in the subjects it touches, and gives fair treatment and assessments to a lot of emerging technology, trends, and fads. He is fair in his treatment of other cosmetic providers in a section devoted to this and advertising, but pulls no punches on the lunacy of ENT's, Oral Surgeons, and others doing procedures they are clealry not adequately trained in performing.

Dr. Perry peppers fairly brief and well-written summaries with spot-on commentary like , "Surgeons who do laser blepharoplasty will admit in the locker room that they use it as a marketing ploy for their practice."

I sampled some of the chapters, none of which had anything I found way off base or inaccurate. You will always hear differences of opinions between Plastic Surgeons over technical issues and subjective things. I found his chapter on breast augmentation informed consent & risks excellent, while wishing he'd come out stronger on telling patients NO when they want implants too large for their anatomic breast borders (one of my personal pet issues)

Notably absent from this Dr. Perry is much in the way of self-promotion, which is a refreshing change from some other books like this I've seen before. This is a book I would strongly recomend for patients, and even other health providers to understand Plastic Surgery procedures.

Rob


I found a great post by Dr. Val on dissecting Michael Moore's "Sicko" documentary. In this film Moore pushes a 100% socialized solution with universal federal medicare-type coverage, modestly salaried physicians, and no ability for people to pay for premium services even if they have the financial ability. Health-care's a mess, but we're not ready to throw the baby out with the bath water.


This idea of a complete socialistic medical system is a non-starter in our country IMO and Dr. Val has some interesting cultural observations on why this is so . She has the perspective of having lived in the Canadian & UK systems, while practicing here now in the USA. I agree 100% with her observations. If you impose the VA system on everyone (which is already an American micro-economic scale "Universal Health" system of sorts), you're going to have more people with basic coverage (a great thing) with better and more standardized medical records (another great thing), while at the same time alienating both Doctors and patients with the red tape, restrictions, and inflexible cost-containment measures those in the VA system are familiar with.

Dr. Val writes:




If they were served up the Canadian system, they’d scream at the tax rates, and become hysterical at the inability to trade up to a platinum level of care for those who have “earned it.” They would not accept the long lines for care and would immediately start a scheme for off-shoring medicine to circumvent the lines.




If Americans were offered the French system, they’d be immediately annoyed by the inconvenience of the office hours (months of vacation are taken at a time by all members of society, including doctors), they’d never use the preventive health measures (they don’t have time for that stuff), and although they’d be glad to receive home health aides for no more excuse than - “I just had a baby and I’d like a government worker to clean my house” – when they
saw the tax rates it would take to make this available to all, they’d find it unacceptable, especially with such high copays and out of pocket expenses..

Over at Slate.com there are some articles about "Sicko" as well. I found the comments by one of Sen. Barack Obama's health care policy guys very interesting. He dismisses Moore's call for a radical single payer system overhaul and astutely observes:



But the main problem with Moore's policy solution is that a national health system wouldn't fix one of our health care system's main flaws—one that people really hate—the denial of service. It just changes who decides, so that the government makes the call.

In one heart-wrenching case in the movie, a woman whose husband has kidney cancer is told by the insurance people that they won't allow an experimental treatment that might save his life. But that scene would likely play out just the same way in a nationalized health system. In those systems, cost-effectiveness decisions get made all the time. Care is rationed. That's what happens if you offer something for free—you have to make rules about who is allowed to get it. So, you forbid smokers from having heart bypasses, or, in a more recent debate in the U.K. about a new hay fever medicine, you just say the medicine is too expensive to be used.

So, to do as Moore wants in the United States, you would need to do more than just overcome the insurance industry. You would need to cut the salaries of doctors, reform the legal system, enrage our allies by causing their prescription drug costs to escalate, and accustom patients to a central decision-maker authorized to determine what procedures they are and are not allowed to get. Unless every one of these changes comes together, Moore's new system would end up costing an enormous amount of money.
There's a column on Slate.com "True Believers: Why there's no dispelling the myth that vaccines cause autism." that's kind of interesting.

At right, a parody MAD magazine cover by blogger Bev Harp pokes fun at those who believe vaccines cause autism.

If you're not familiar with that controversy, the short version is that there was a contention that a mercury-based preservative (thimerosol) used previously in the Mumps-Measles-Rubella (MMR) vaccine was responsible for making children develop autism.

This past week concluded a 12-day hearing before the US Court of Federal Claims. The hearings largely confirmed the scientific consensus that there's no connection between autism & thimerosol. A story in the Washington Post summarizes thishere.

With the medical literature surrounding mercury poisoning reviewed in the hearing (which has never shown autistic-like effects), the dose are often 100's to 1000's of times higher than what someone would receive in the MMR vaccines. A number of large epidemiological studies have shown no link to either MMR or other thimerosal-containing medicines.

From the Slate.com article:


People who study irrational beliefs have a variety of ways of explaining why we cling to them. In rational choice theory, what appear to be crazy choices are actually rational, in that they maximize an individual's benefit—or at least make him or her feel good.

Blaming vaccines can promise benefits. Victory in a lawsuit is an obvious one, especially for middle-class parents struggling to care for and educate their unruly and unresponsive kids. Another apparent benefit is the notion, espoused by a network of alternative-medical practitioners and supplement pushers, that if vaccines are the cause, the damage can be repaired, the child made whole. In the homes of autistic children it is not unusual to find cabinets filled with 40 different vitamins and supplements, along with casein-free, gluten-free foods, antibiotics, and other drugs and potions. Each is designed to fix an aspect of the "damage" that vaccines or other "toxins" caused.

In reality, autism has no cure, nor even a clearly defined cause. Science takes its time and often provides no definitive answers. That isn't medicine that's easy to swallow.....Another explanation for the refusal to face facts is what cognitive scientists call confirmation bias.

Systems of belief such as religion and even scientific paradigms can lock their adherents into confirmation biases. And then tidbits of fact or gossip appear over the Internet to shore them up. There's a point of no return beyond which it's very hard to change one's views about an important subject.

Then, too, the material in discussion is highly technical and specialized, and most parents aren't truly able to determine which conclusions are reasonable. So they go with their gut, or the zeitgeist message that it makes more sense to trust the "little guy"—the maverick scientist, the alt-med practitioner—than established medicine and public health. "History tells us that a lot of ground-breaking discoveries are made by mavericks who don't follow the mainstream," says Laidler. "What is often left out is that most of the mavericks are just plain wrong. They laughed at Galileo and Edison, but they also laughed at Bozo the Clown and Don Knotts."
.....Joined together on the Internet, these actors create a climate of opinion that functions as an echo chamber for conspiracy dittoheads.



The activist community in the breast implant debate is an obvious parallel to this. There's tremendously compelling science not confirming their contentions of related illness, but there still exists heart-felt conviction by these women that their breast implants caused their medical conditions.

A whole counter-culture of "implant survivor" support groups and websites have come up and are filled with anecdotes outlining their beliefs. On display are often desperate stories of depression and swapped tales of homeopathic voodoo-like potions to "detoxify" them of silicone, platinum, mold, etc... The reactions on display, like the parents of some autism patients, seek to point the finger at someone who must be responsible for their illness. This may have been a legitimate question in the late 1980's, but we long since know this to not likely be true with silicone or saline breast implants.
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