Once again, Angela and I found ourselves stumbling around trying to figure out where to go in the hospital. We actually found the right spot pretty quickly, but our preceptor had not arrived yet. Thus, we awkwardly stood around, unsure if this was the correct meeting spot. However, once Dr. Chen arrived, I quickly forgot about prior events and prepared myself for the many patients ahead.
Today, our preceptor was scheduled to see many of his outpatients on chemotherapy. I expected a very solemn atmosphere with each patient, but in actuality, most of his patients were in good spirits. I was really surprised by how much each patient was able to joke around and just by how happy they were. Most of these patients did have their cancer under control without any significant side effects from the chemotherapy, which may explain their attitudes.
Most of the information I absorbed throughout the day revolved around chemotherapy regimens and reasons to choose certain drugs over others. The majority of his outpatients today had breast cancer. Dr. Chen usually applies anthracyline + cyclophosphamide or a targeted drug for chemotherapy regimens. Targeted treatment is generally guided by immunohistochemistry or FISH testing to determine what cancer associated proteins are positive (i.e. HER2 vs ER/PR). If HER2 is positive, then chemotherapy involves combo therapy with herceptin (or trastuzumab as we learned it), which is a monoclonal antibody drug that targets HER2. Herceptin was usually used in combo with Paclitaxel, a mitotic inhibitor. If ER/PR is positive, hormone therapy is indicated with tamoxifen or aromatase inhibitors. In one unique case, a patient's tumor grew while on herceptin therapy and according to policy, this therapy could not be covered by insurance anymore. Thus, the prototype drug could no longer be administered and had to be switched to pertuzumab despite the possibility that it may not have had adequate time for action. This further reinforced the fact that best treatment options are not always what is implemented due to patient response and insurance issues. Some of his patients had distant metastasis usually to the liver, lungs, or bone. In these scenarios, more aggressive chemotherapy or radiation is necessary to try to contain the cancer. For bone cancer cells in breast, prostate, or multiple myeloma cancers, bisphosphamide is often applied to control the extent of osteolytic lesions. In the end, I realized treatment is constantly altered and guided by not only testing of cancer markers but also by patient response and insurance coverage.
Although I was exposed to a lot of information, the most mind-blowing fact was how much medicine can be dictated by factors separate from doctor and patient. I feel in medical school we are branded with the idea of the doctor-patient relationship while often neglecting insurance and even pharmaceutical issues. Whenever Dr. Chen explained any of his treatment decisions, he almost always discussed insurance policy (what drugs insurance would cover and why) and phase testing of drugs. Many of the drugs he administered are relatively new and in phase III, which means there is not currently much long term usage data. Physicians need to stay up-to-date on drug testing to be able to provide optimal treatment for their patients. Ultimately, to be at least an adequate physician, I need to strive to look beyond the obvious importance of the doctor-patient relationship and learn to integrate insurance and pharmaceutical information to best provide for future patients.
*Note: any incorrect information may be due to translation issues...
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