December 30, 2011 - More on Out-of-Reach Zevalin

Dr. Vance Esler, oncologist and blogger, posted a comment on my last entry that's worth my cutting and pasting it here:

"Carl, it is an oversimplification to say that oncologists don't refer patients for Bexxar or Zevalin because it isn't in their own personal arsenal. In fact, a fair amount of the treatment is done by the medical oncologists.

Every day medical oncologists take financial risks. We buy and administer expensive drugs, hoping that the insurance carriers will reimburse us enough to cover the costs. We are used to this.

But Bexxar and Zevalin are administered by nuclear medicine physicians, and they are NOT used to taking the financial risks. Furthermore, they don't know how to bill for such drugs, and they are afraid to try.

So no one in our 600,000 person service area offers the treatments. The medical oncologists are not licensed to dispense the drugs, and the people who are licensed are afraid to take the financial risks.

Thus, the medical oncologists are forced to look for alternatives."

Interesting perspective Vance has: that it tends to be the nuclear-medicine doctors who aren't up to speed on administering radio-immunotherapy agents like Bexxar and Zevalin, and are therefore more likely than oncologists to be at the root of the problems these effective medications have had in making their way into the marketplace.  Vance knows a lot more about this than me, so I'm happy to say that I stand corrected.

I find it pretty shocking that his 600,000-person service area in Texas doesn't have a single qualified specialist who's stepped up to the plate to offer these treatments to patients who could use them.

Still, to me this points out, once again, the shortcomings of our free-market, entrepreneurial approach to healthcare funding, that puts doctors in the position of having to assume unacceptable financial risks in order to deliver proven, effective treatments to their patients.  Those who are determined to keep the government out of healthcare funding are continually spouting the line that, left alone, the invisible hand of the market will eventually even everything out.  This is a clear example of just how false such economic dogma is, when applied to cancer treatments.

December 23, 2011– Mademoiselle Zevalin’s Empty Dance Card

Interesting article, here, about the difficulties ibritumomab tiuxetan (Zevalin) has been having, getting accepted as an effective treatment for non-Hodgkin lymphoma.

So, at the Oncologists’ Ball, why is Zevalin – which is actually a pretty hot little number – treated like such a wallflower?  Dr. John Pagel, of the Fred Hutchinson Cancer Research Center and Seattle Cancer Care Alliance, thinks he understands the reason:

“Unfortunately, oncologists still have to refer the patient to a radiation oncologist or nuclear medicine physician for administration of the drug, which can be a barrier for treatment in some cases.”

Gee, d’ya think?

For most oncologists to prescribe Zevalin for their patients, they have to give up the privilege of dispensing treatment themselves.  Since many oncologists – who have invested big bucks in elaborate chemo suites, where they dispense medicines costing tens of thousands of dollars – earn their money not just from the medical wisdom they dole out, but also from the meds, telling a patient “I think Zevalin could help you” means foregoing the income from several months of costly chemo treatments.

Is it any wonder so many oncologists stick to the classic approaches, which just so happen to use the treatment agents they’re licensed to dispense?

Zevalin, along with Bexxar (the other leading drug of this type), is the highly-effective Rituximab bonded with radioactive particles.  The CD-20 targeting agent in Rituximab seeks out and travels to the malignant cells – unleashing Rituximab’s own cancer-fighting properties – but then the radiation zaps ‘em again.  It’s a potent one-two punch.

Sort of reminds me of the sharks with laser beams that were the weapon Dr. Evil lusted after in the silly Austin Powers movies.  Rituximab’s the shark.  Radiation’s the laser beam.  Get it? (Can you hear the screams of a metaphor being stretched beyond all recognition?)

How do you suppose radioimmunotherapy studies of drugs like Zevalin are received at professional conferences, when very few of the members of the professional association are licensed to dispense the drug?  (Doctors who administer radioimmunotherapy have to be double-qualified, both in oncology and in either radiology or nuclear medicine.)  These docs-on-holiday hear reports of the science behind these treatments, and they can’t really argue with it, but it can’t fail to enter their minds that, in order to prescribe these drugs, they’ll have to let some other doctor’s practice collect the revenue.

I’m not charging oncologists with running some kind of cartel or cover-up.  It's just that I'm enough of a Calvinist to point out that they’re only human, and therefore such a thought can’t fail to enter their minds.

Again, it’s the basic structure of our healthcare system that’s the real root of the problem. Force doctors to function as small-business entrepreneurs who are paid according to treatments dispensed rather than according to clinical outcomes, and a proven drug like Zevalin gets pushed to the back burner.

It would be interesting for someone to study which sorts of oncologists are referring patients for radioimmunotherapy more often – those who own their own practices, or those who work for organizations like the Mayo Clinic, where they’re all on salary.

Are there any investigative journalists reading this, looking for a scoop?  Just crunch those numbers. I’ll bet you’ll see a correlation.

December 12, 2011 – Blue Christmas

It’s been a while since I’ve posted, I know.  I had the fall stewardship campaign at the church, then Thanksgiving, then the start of Advent – all the while dealing with the sandwich-generation issues that are my life right now: young-adult kids coming and going, and caring for my mother who lives nearby and has Alzheimer’s.  Life has been busy (and, thankfully, healthy)!

Yesterday, for the first time, we offered a Blue Christmas worship service at the church.  It’s something I’d hoped to explore in previous years, but it took the enthusiasm of our church’s Associate, Linda, to get it organized.

What a blessing!  Attendance was not large (nor did we expect it to be).  We’d promoted the service as a focused pastoral-care outreach to a select group of people: those who have experienced recent losses, and who feel a bit left out amidst the traditional pre-Christmas merrymaking.  For those who participated, it was a rich and meaningful experience – due, in large part, to Linda, who put together a carefully-crafted order of worship that emphasized the presence of God and the quiet beauty of the Advent season.

Judging from what I know of those who were present, most of the losses were due to bereavement, although we were careful to speak to losses of all kinds, including the loss of jobs and income in this difficult economy.

Cancer, of course, brings its own losses.  Even those who are fortunate enough to go into remission have lost the sense they once had of being healthy.  We’re reminded of that every time we fill in a medical-history form.  Always there is the reality of the cancer, and the thought in the back of our minds that someday it could come back.

Towards the end of the service, everyone was invited to come forward and light an individual votive candle in a blue-glass holder, in memory of their loved one or in recognition of whatever other loss they may have experienced.  The people did that by means of a white, hand-held candle they passed from person to person.  Each one used it, in turn, to light his or her own candle, then passed it to the next person, and so on.

It struck me, at the time, how powerful was the symbolism of that simple act.  Here was a group of people, each of them bearing a heavy burden of grief.  The road each one is walking is, by its nature, profoundly alienating.   Yet, each one passed the light to a fellow believer, all the same.

We receive ministry from others, yet Christ also calls us to offer it.  Even in a season of personal darkness, we can very often still find a little light to offer to another.  This is what life in Christian community, at its finest, is all about.

There are some who maintain that one of the surest ways up and out of the pit of depression is to try to do something for others, however difficult it may be to get started on that.  I think there’s a lot to what they say.

The night before the Blue Christmas service – knowing how few are the liturgical and musical resources to use in planning such a service — I felt led to write the text of a hymn.  It was too late to get it into the bulletin for this year, but maybe we’ll use it next year.

The hymn is set to the hauntingly beautiful tune of The Coventry Carol - a familiar tune to many, but not one we’re used to singing as a congregation.  Not many people who enjoy listening to the Coventry Carol on their Christmas CDs are aware of this, but its lovely melody is desperately sad. It’s the keening lament of the women of Bethlehem, after their male babies and toddlers have been slaughtered by the soldiers of King Herod.  (According to Matthew 2:16-18, Herod was bent on murdering the young Jesus, whom he perceived as a threat to his rule.)  “Lullay, lullay, thou little tiny child” is a lullaby, to be sure, but it’s the last lullaby sung by a grieving mother to the dead child in her arms.  Pretty grim stuff, but also very powerful in a raw, emotional way.

(Scroll down for the hymn text...)

Comfort Your People, Lord

A Hymn for Blue Christmas Worship Services
Text by Carlos E. Wilton
Tune: “The Coventry Carol”

O Lord, we bring to you, this day,

Hearts that are raw with pain:

For sorrow has companioned us,

And in our lives does reign.

You promise to make all things new:

Comfort your people, Lord.

Would that we could turn back the clock

And for one precious hour

Reach out, clasp hands, and touch again

Love’s fragile, with’ring flower!

You cherish all times in your hands:

Comfort your people, Lord.

All through our lives we’ve trusted you

To be most fair and kind:

Though, in the dark night of the soul,

Anger enthralls our minds.

For freedom you have set us free:

Comfort your people, Lord.

We have not always trusted that

Fairness has been your way.

Too soon it’s seemed to watch our dreams

Float up and fly away.

For good, all things together work:

Comfort your people, Lord.

My soul, why are you so downcast:

Caught up in grief’s malaise?

We trust the day will soon arrive

When we will sing God’s praise!

Not Yuletide mirth, but Easter joy:

We ask this gift, O Lord.

Copyright © 2011, by Carlos E. Wilton.  All rights reserved.  Permission is given for congregations to reproduce the text of this hymn in worship bulletins, as long as the copyright information is included.