Vanredno stanje

Moj frizer, Amerikanac grčkog porekla, je nakon očeve smrti proveo mesec dana u Atini da bi prodao stan—neplanirano, pošto nije znao da je Grčka zatvorena u avgustu. Para imao nije, pa je vreme provodio gledajući grčku televiziju (“6 glava preko celog ekrana, viču jedna na drugu”) i razgovarajući sa ujakom i njegovim prijateljima, uglavnom o prljavim, pokvarenim, lenjim Albancima.

Utisak: ljudi su svuda isti. Svako ima svoje crnce i Meksikance, i svoj FOX News.

Juče su grupe siromašne omladine sa viškom vremena i manjkom ciljeva—možda a možda i ne podstaknute vrhom baltimorske sive i crne ekonomije—lomile, palile, i krale po svom gradu. Policija je bacala suzavac, omladina je bacala cigle. Razlog za demonstracije brzo su zaboravili i demonstranti, i policija, a pre svih novinari.

Da nisam na odmoru, bio bih iznerviran jer je deo grada kojim svakog jutra idem na posao bio u haosu. Kao što je 23-ojka koja me je vozila od Karaburme do Instituta za histologiju stajala dok su palili ambasade u Kneza Miloša.

Ljudi su svuda isti, osim kad nisu.

Naša zalutala omladina voli da pali, lomi, i pljačka centar grada. Baltimorska uništava sopstveni, već propali komšiluk. Naša se nominalno bori za Kosovo (ili, izgleda, za istrebljenje suparničkog tima), baltimorska protiv policijske brutalnosti. Situacija u Baltimoru je jasna: narko preduzetnici sa jedne strane, policija sa druge, siromašni crnci kao pijuni u sredini. Ko se drži po strani popije zalutali metak, suzavac, lom vratnog pršljena. U Srbiji se teže razaznaje ko koga napada, podržava, podstiče, i brani. Ne znam šta je bolje, i ne znam za koga.

Pretpostaviću da ste kao svaki dobar akademski građanin odgledali The Wire. Dejvid Sajmon je na svom blogu već ranije pisao kako je čudo što do bacanja cigli nije došlo ranije, i u većoj meri. Neki su u komentarima to protumačili kao podrška jučerašnjim protestima. U svom poslednjem tekstu je zamolio ljude da prestanu sa paljenjem, i da se vrate kući. Neki drugi su u tome videli bogatog belca koji crncima naređuje da ćute.

Sviđa mi se kako Sajmon razmišlja, a i napravio je odličnu seriju, pa ću reći da je u pravu čim ga napadaju obe strane. To nije neki argument, ali i pored skoro pet godina provedenih u Baltimoru, bolji nemam—razmišljao sam o drugim stvarima. Ako vas interesuju rasne borbe i rat protiv droge u Americi, a imate par sati, pročitajte Sajmonove stare članke i odgledajte ovo. Ja vam neću uzimati više vremena.

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Kaposi’s: not your every day sarcoma

Kaposi’s sarcoma is an often misunderstood disease. You don’t need to have AIDS to get it; if it is AIDS-associated it doesn’t always disappear with antiretroviral therapy; and if it does it may come back years later. Even oncologists in the US don’t see it often, let alone podiatrists—hence some bizare treatment recommendations in the slides below.

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The pitfalls of ultrasubspecialization

If you haven’t yet seen the new PBS documentary on Cancer, do it as soon as possible. A free stream is available on the PBS website but it is well worth the $15 on iTunes.

It makes many good points, one of which is the siliness of viewing cancer in general, or of any particular organ, as being a single entity. Genitourinary and GYN malignancies are sill fresh in my mind after this last rotation, so an example that comes first is prostate cancer. Most have your standard testosterone-dependent, androgen deprivation therapy-sensitive cells. Once they stop responding to hormonal therapy, treatment is still targeted towards the (now mutated) androgen receptor. Small cell prostate cancer, however, looks and behaves differently—tending to be bulkier, more aggressive, and having earlier visceral organ metastases. Ultimately, we treat it more like its namesake in the lung, with cisplatin and etoposide.

That was an easy distinction to make, since small cell prostate cancer looks nothing like adenocarcinoma under a microscope. Not so for breast cancer. We now know that it is at least four diseases which are at first glance all the same: luminal A (hormone receptor-positive, Her2-negaitve); luminal B (HR-positive, Her2-positive); HR-negative, Her2-positive; and triple-negative (also called basal-like, though definitions of basal-like breast cancer vary). The first three, which we are now able to distinguish with immunohistochemistry and FISH, have different behaviour, treatment, and prognosis. The fourth is a catch-all category that probably contains many different diseases we don’t know about yet. Some of those triple-negatives may have more in common with colon or lung cancer than they do with other malignancies of the breast.

Which organ the cancer is in should be important to a surgeon or a radiation oncologist, who have to deal with the anatomy. But should medical oncologists subspecialize by organ, or by cell? Why is a neuro-oncologist better suited to treat primary CNS lymphoma than a hematologist whose main interest are aggresive lymphomas? Does a GI oncologist have a better skillset and knowledge base for dealing with neuroendocrine tumors of the pancreas than an oncologist who deals with endocrine gland malignancies? Are there other, not so obvious connections between different cancers that we are missing because of ultrasubspecialization?

I don’t know enough oncology to answer any of these questions, but they are interesting questions to make.

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Male breast cancer, a slide show

As the year winds down, these tumor board presentations will get less frequent. For now, though, it is still once a month. My latest, on breast cancer in men, seemed to be well-received. I suspect it was because, unlike most rare cancers, this one was easy to fit into a preexisting pattern: it is just like female breast cancer, except for… And voilà—you get quick and easily understood knowledge about a whole new disease entity.

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Apple’s App Store rules, Dosegate edition

First they came for the nerds.

Now they are coming for the doctors (see What’s New in Version 3.0.5). The makers of MedCalc, the best medical calculator app out there, explained what happend in detail1. This was the rule they were supposedly infringing:

22.9 Apps that calculate medicinal dosages must be submitted by the manufacturer of those medications or recognized institutions such as hospitals, insurance companies, and universities.

Nevermind that many doctors view themselves as institutions—this is an idiotic rule. Is University of Baltimore, which has no biomedical science courses or programs, allowed to publish a drug dose calculator? Is GEICO?

The FDA has issued guidance for mobile medical apps. It specificaly allows calculators that use generally available formulas, and forbids apps which calculate radiation dosage, but does not mention drugs. Where, then, did this rule come from?

It is, of course, the same App store rules that allowed these pearls of quackery.

It’s madness, and it’s maddening.

  1. Seeing that URL made me appreciate the developers even more. 

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Opasnosti vrebaju

Pacijent u ordinaciji ima pedesetak godina, izgleda mlađe. Oćelaveo od terapije, mada bih po konstituciji, odeći, i stavu—dva metra i mišićav, tri krsta i brojanica, vojnički i za dva decibila preglasan—pretpostavio da nikada nije imao bujne lokne.

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The more you know…

If the unstated goal of these rotation post-mortems was to summarize what I had learned, a single post may not be enough for breast cancer. Six weeks ago, I knew that it was common, maybe overdiagnosed, possibly overtreated, and beating all other cancers for research funding by a vast margin. All this was a vague sense of being informed—like a NYT reader may feel after reading the Sunday Magazine feature—rather than actual knowledge.

Having talked to a good number of women with breast cancer, and worked with a few attendings dedicated to the field, I know it enough to know that I need to know more; but also enough to keep me interested. What from the outside looks like cookbook this-marker-means-she’s-getting-that-treatment medicine is in fact an intricate work of knowing your patient, figuring out where she stands in the heaps of data generated by decades-long studies following thousands of women on different protocols, discussing the options, and coming to a mutualy agreed decision1. Hard work, all of it.

Harder still is working on those data-generating trials. Anyone can think of a clinicaly relevant question, but can they make it into a feasable protocol? Can they gather a team to manage all the patients in the center, and all the different centers? Can they manage that team? Looking at a recent set of trials you will hear more about soon, the scale boggles the mind.

Side note: “We don’t have a crystal ball” is common oncspeak for “I don’t know what your prognosis is”2, but if a person has breast cancer what are the Gail model or Oncotype DX if not (developing, imperfect) tellers of fortune? And wouldn’t it be great to have a similar set of tools and statistics for all cancers?

So, not going into the field, but thoroughly impressed.

  1. Which is—truth be told—what we should do for any cancer, or illness. Alas, most diseases lack data, options, or both. 

  2. Or in the paternalistic dialect of the language, “I don’t want to tell you that you prognosis is poor”.  

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