Curing Cancer: A Great Achievement That Would Shock Our Health Care System

The history of science is littered with a recurring theme of unintended consequences tarnishing man’s great technological advancements.

As a physician I have often pondered the unintended impact that many of the advancements of medical science have had on our society. Our achievements have blessed us and improved lives but also have created conditions that cause problems for our system.

At present I can think of no issue in medicine that has more of an impact on human life and the health care system than cancer. Cancer is a disease that touches everyone’s life at some point. In popular culture a cure for cancer is something that is often imagined as a sentinel moral and scientific achievement for our species.

While I agree with this idea I also see a cure for cancer as a great challenge for our health care system. I believe that the unintended consequences of curing cancer would be unparalleled and potentially could be a tremendous shock to our health care system.

The system would have to absorb all the patients whose lives would be saved. One need only look at the recent history of medicine and the state of our health care system to assess the potential side effects that outright curing a disease that kills about 21 percent of Americans might have. Already the rapid increase in life span we have experienced (The average life span is 78.4 years, up almost a decade from the 1960s) has not come without unintended consequence of cost and strain on our system. As human beings live longer and treatments grow more and more sophisticated and expensive the costs of their care grow more and more.

For example 30 years ago a diabetic patient may have died from a heart attack at age 50, but today modern medicine now very likely will keep this patient alive through an emergency with clot busting drugs and procedures. Now he will live longer, perhaps much longer.

Imagine the cost and impact this will have considering the staggering cost of years of care for a medically complicated patient. He will need years or perhaps even decades of insulin, statins, beta blockers, ace inhibitors, anti hypoglycemics, follow up primary care visits, needed labs, urinalysis, hospitalizations when infections or complications arise, yearly podiatry visits, yearly opthamology visits, nephrology visits, endocrinology visits, cardiology visits, care for whatever else might come up in a medically complicated patient and perhaps even several years of nursing care at the end of the road.

Obviously in moral terms we can all agree that it is a wonderful thing, but the facts are the facts and years more of care will cost precious, and limited, resources. As this scenario happens in vivo every day thousands of times over in our hospitals the strain on the system grows greater and greater. The proof is in the pudding: keeping sick people alive longer may be the right thing to do, but the costs of their care are taking a massive toll on our system. For example right now Medicare is set to run out in 2029. To me that is a terrifying fact.

Now imagine what happens if we cure a disease that ultimately kills 21 percent of the American population. That fifth of our population would live on to ultimately die of something else and in the meantime they will need nursing care, doctors, drugs and diagnostic studies.

We have already seen that as people live longer based on recent medical advances the rates of Alzheimer’s and other dementias is rising at a staggering pace. Many people now live in nursing homes for years at the end of life in a state of chronic illness, bouncing between nursing home and hospital. The costs of care in the last months of life especially for the chronically ill are staggeringly expensive and inefficient.

Keep in mind that while often times cancer strikes people with otherwise good health, it tends to strike older individuals as well as people with many other illnesses. We would be curing many people who were likely to have other chronic diseases. For every one otherwise healthy adult or child that cancer would save there would be at least as many very sick or very elderly who want and deserve treatment so they can live. After all, who should be the one to tell them they can’t have it? (curing cancer also raises countless social and ethical questions like this, which is another blog entry altogether!).

I believe a cure for cancer would be unprecedented not only as a moral and scientific achievement, but also as a potential major shock and threat to our already strained and faltering health care system. The burden a cure for cancer would throw onto our system could seriously tarnish the shine of what would be one of man’s greatest achievements. We have already experienced this effect with other medical advances.

It would be a shame if the consequences of curing a disease that is the scourge of mankind would be strained resources and worsened care across the board, especially for the 60 percent of people who will never have cancer in their lives. Like all great achievements the good of curing cancer would undoubtedly outweigh its harm and obviously man should do everything he can to achieve this. As a species we must continue to advance and find ways around the unintended consequences of our gains. In that way we can minimize the fall out and reap the benefits of our well intentioned efforts to improve lives and serve humanity.

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What should we do with the mentally ill?

Another year.  Another tragedy involving guns, violence, the internet and the mentally ill.  The archetype of the sadly deranged misanthrope becoming disenfranchised and turning to serious violence has become all too routine for our nation.

This time the tragedy is in Arizona in a Safeway parking lot with 6 dead and dozens more  wounded.  As I watched the memorial service two weeks ago for the victims I can not help but recall the spat of memorial services our nation has watched and experienced over the last several years.  From the massacre at Columbine High School to the horrors at Virgina Tech to this recent  shooting at Congresswoman Gabrielle Gifford’s event our nation has suffered a seemingly continuous chain of high-profile and tragic gun massacres. 

The reports detailing the alleged perpetrator Jared Loughner portray a disturbed individual.  The excerpts from his writings and his social media pages detail an intelligent mind overcome with delusion, paranoia and disorganized thinking.  In my opinion, from the information available I believe it is reasonable to question if this young man suffered from paranoid schizophrenia. 

It is presumptious to assume we know anything about this person but whether he fits the diagnostic criteria of a schizophrenic there is a pattern in our society of  high profile violence that takes it’s roots in mental illness.  This recent shooting brings to mind some of the larger issues surrounding this pattern as well as calling into question some of the ways that our country is managing those with severe mental problems.

For those who don’t know much about it Schizophrenia is a tragic mental illness that ruins lives and destroys families.  It is often miscategorized in the popular media, and many people with this diagnosis go on to lead functional and normal lives. That said, Schizophrenia is every bit as much a tragedy as a diagnosis of cancer, ALS or any other “medical disease.”    Schizophrenia is categorized by disorganized thought patterns, delusions, auditory hallucinations, poor communication ability/social skills, occasionally paranoia and some other bizarre symptoms. 

 Contrary to its categorization in the popular media schizophrenic patients do not typically experience visual hallucinations.   Despite what drug companies or even some psychiatrists might insist, the underlying cause of schizophrenia is extremely poorly understood and there are no clear cut genetic or biological roots, though the disease does tend to run in families with a stronger predilection for twins.

This crime in Arizona taken by itself is a tragedy but in the context of a string of other similar crimes committed by similar minded individuals it also raises the larger question of what we as a society are doing with our mentally ill.

In 2011 for the most part the mentally live among the general population in the community.  It has been almost a half a century since John F. Kennedy began the process of closing the insane asylums that, now abandoned, eerily dot the nation.  Prior to the 1960’s the mentally ill were locked away from the rest of society but now serious mental illness today is usually managed with quick inpatient hospitalizations to stabilize patients for several days and outpatient psychiatric care in the community.  

This approach was made possible by the development of the so-called “antipsychotic” drugs, such as Thorazine and Haldol, which were used to treat schizophrenia and help schizophrenic people function so that they could theoretically survive in the community.   A second “generation” of these drugs such as Seraquil,  were released in the 1980’s and 1990’s because they initially advertised a better side effect profile than the older drugs, but subsequent studies have questioned that.

The drugs used to treat schizophrenia work by blocking Dopamine receptors in a part of the brain called the mesolimbic cortex.  There is no concrete evidence that dopamine oversensitivity plays a role in psychosis, but this area of the brain is key in allowing communication between the frontal lobes of the brain, which processes judgement and cognition and the limbic areas which is responsible for processing emotions (this is extremely simplified).   No one knows what makes a schizophrenic, but these medicines likely work by blocking neurotransmitters and therefore suppressing cognition, which to the tortured mind of a schizophrenic can produce symptom relief and improve  lives.

Well this sounds all well and good, the problem is that these drugs come with tremendous side effects to some users.  Some patients report that they make them feel unhuman and zombie like.  Others suffer severe neuromuscular disorders or weight gain and other endocrine problems.  While to some patients the medicines are a god send,  some mentally ill patients won’t or can’t tolerate the side effects.

Furthermore, the medicines seem to show different efficacy in different people.  For some the medicines work well, but for others they don’t show the same effectiveness.  The truth is that for all we know, the disease we call schizophrenia is hundreds of diseases with similar outward traits, but very different underlying disease processes.

The end result is that many schizophrenic patients either don’t take these medicines or don’t experience a radical change in their symptoms and are untreated.   This is a problem because studies repeatedly show that the schizophrenic people especially when untreated have a much higher incidence of violent crime than the rest of the population (as an aside the type of mental illness that has the most violent crime associated with it is substance abuse, including alcohol).

Considering the pitfalls of treating schizophrenia, the tendency of schizophrenic to violence and the rash of high profile violent crimes involving victims who appear to be suffering from the symptoms of this disease, I think it is reasonable to question if our strategy for managing the seriously mentally ill in the community is the best approach for our society to take.

 As a former residential counselor for the Italian Home for Children, a former social worker for Massachusetts DCF and now a medical resident I can say that I have seen up close schizophrenia in all the stages of its natural history from in utero to early in life to adulthood and even to death.  I believe that schizophrenia is a horrible tragedy and that the people who suffer from it are themselves very much victims.   I like the idea of these people being included into society as much as possible because I think they suffer a real, terrible disease and I feel uncomfortable with them being punished for that.  After all we don’t lock away people with AIDS or Cancer.  

In my opinion there is no perfectly “just” way to manage this situation and the question is how do we as a society handle a sub-segment of the population that has a disease that is difficult to manage and makes them apparently more prone to violent acts.   It is not “just” to lock away the victims of mental illness but the question here is is it more just than the alternative.  Is it more fair to restrict the freedoms of the mentally ill than it is to expose innocent people to violence?   Is there a middle solution? What is the greater injustice?  

I feel a tremendous amount of compassion for those who suffer mental illness but I also feel compassion for the victims of violence.   When I see the faces of the victims of the tragedy in Arizona I can not help but wonder if we are doing the right thing and if it is preventable.   I can say for sure that I do not have an answer to this question, but I do believe it is a question based on recent events that is worth asking.

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