Terra Infirma

Can bone-marrow transplants save breast-cancer patients? There's little middle ground in the debateand lots of uncharted territory.

Instead, procedures should be judged by two things, Jones says: their toxicity and whether they kill more cancer than earlier treatments. "Statistics tell us we have to look at tumor shrinkage by waiting to see how long patients live. But what if you could measure more accurately how much of the tumor is killed? The doctor says, I have two treatments, equal in toxicity, but one kills more tumor than the other. Which are you going to pick?"

Meanwhile, all the debate is taking place under the far-from-disinterested scrutiny of the insurance industry. For the time being, ASCO is recommending that insurance companies continue to pay for bone-marrow transplants--a position Jones passionately supports. "Dose intensity is only a component of what we're trying to do here," he says. "How are we supposed to do this work in a health-care system that denies experimental treatment? We've spent ten years creating a model on which we can build. We're working with the immune system, with monoclonal antibodies...The bio-tech people are creating ideas five times faster than we can test them. You don't want me to be ten years behind the loop in terms of testing what these companies are able to produce."

And you don't want patients to be stuck in the middle, either. "Think of what patients are going through when they see us wringing our hands about this and nerding out when it's all opinion," says Jones. "It's all editorial."

Patty Kealiher has seen a lot in her seventeen years as an oncology nurse. A brisk, healthy-looking woman, she has mixed and given chemos, held patients' hands, cleaned up vomit, offered advice, memorized jokes to amuse and distract her patients. She has watched people she's come to love die; she has celebrated with those who outlived all predictions.

Kealiher has worked with bone-marrow transplant for the last eight and a half years--most of them with Jones and Shpall at University Hospital. She began work at Presbyterian/St. Luke's on April 1--"my favorite holiday," she says.

"High dose is the only thing that works," she says unequivocally. "Wimpy chemo doesn't cure cancer."

In her work, she has seen people thrive who were not expected to live. She speaks of Connie, diagnosed with terminal cancer in 1991 and now apparently disease-free. "She would be dead by now," Kealiher says, "if she hadn't gone through the bone-marrow transplant." She remembers Gladys, who collapsed at work and was diagnosed with breast cancer that had spread to her spine. "She went to see a local oncologist who said, 'Dang, I'm really sorry--how about some tamoxifen?'" Since tamoxifen only prolongs life, Kealiher encouraged her to see another doctor, and Gladys ultimately opted for a more aggressive approach that included bone-marrow transplant. "She's a year out, and she still continues to improve," says Kealiher. "I don't know if we cured her, but she would have gotten only a few years doing tamoxifen."

Eventually, Kealiher hopes, advanced breast cancer will be a chronic disease to be managed rather than a fatal one. "My career is very rewarding," she says. "This is the most intense, frightening time of my patients' lives--God help them if they have to go through something worse--but we're giving them a chance they might not have ever gotten."

Still, the work can be difficult. Kealiher speaks of a patient--another nurse--who got an infection and died during chemo. "She was young and healthy, doing the treadmill, and dead two days later. It was horrible.

"Sometimes you're just so zapped, so emotionally and physically drained," she says. "Often I'd get home, make some dinner, sit in front of the TV and just stare at it. Oncology nurses pretty much give everything they've got."

Boulder oncologist Dr. John Fleagle believes the studies must be taken seriously. "I think it would be fair to say that the longer you practice medicine, the harder it is to be dogmatic," he says. "Things change, treatments change, even concepts change...One thing I've learned is that all those anecdotal and life experiences that help you make decisions really need to be filtered through an understanding of research. Because truth, at least as I understand it, is based on research. And I have to listen even if the research is counter-intuitive or it hasn't been my belief system.

"Practicing medicine is not just a matter of opinion; if it were, it would be dangerous. More dangerous than it is.

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