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Cancer Needs A Bailout

Senator Ted Kennedy’s death from brain cancer underscores the urgent need for more funding of basic cancer research.  Despite the best efforts of a team of top doctors, Kennedy died 15 months after the diagnosis of a malignant brain tumor called glioblastoma.  Over the past ten years, some progress has been made against this deadly illness and the silhouettes of some promising new approaches are becoming visible.  But our treatment options remain woefully inadequate.
The annual budget of the National Cancer Institute (NCI) is just under $5 billion.
With over 560,000 cancer deaths each year, that comes to less than $10,000 in research spent for every cancer death. That simply is not enough money spent on a problem that strikes almost 1.5 million Americans each year and causes nearly one of four deaths.
Research for certain cancers is especially under funded.  Earlier this year, I helplessly watched a dear friend and patient die from esophageal cancer, both of us knowing that only 22 million dollars each year – about $1,500 per death – was being spent by the NCI on the disease annually.  One reason is that patients with esophageal cancer don’t have a strong advocacy group to push for their fair share of the funding pie.  Lung cancer, which tops the list of cancer killers in America, only gets about $1,500 per death.   At the top of the list based on research spending per death are cervical cancer (about $19,000), breast cancer (about $14,000) and brain cancer (about $12,000).
Click here for a chart that I compiled with the help of statisticians at the NCI that breaks down government spending on the top cancers.

Of course, there shouldn’t have to be a competition among cancer advocacy groups.  There should be adequate funding of basic medical research to help discover the underlying cellular mechanisms that many cancers share and that hold the key to prevention, early diagnosis and effective treatment.  But there’s not enough money for our young researchers.  In 1980, almost 25 percent of first independent government grants went to scientists under age 35; that figure has plummeted to only 4 percent as the first-grant age rose from 34 to 42.
Faced with increasing competition for shrinking dollars, many of our best and brightest are considering other careers.
My cancer patients desperately need a bailout.  The best way to increase our spending on cancer research responsibly is through health care reform.  The Institute of Medicine has estimated that about 20 percent of the annual $2.5 trillion in health care costs is unnecessary. That’s $500 billion annually or 100 times the current budget of the National Cancer Institute.  There could be no better tribute to Senator Kennedy or wiser investment in our own futures than to fix a broken system that threatens to bankrupt us while inadequately addressing one of our most devastating health problems.

For this week’s CBS Doc Dot Com, I take you behind the scenes to an edit bay at the CBS Broadcast Center in New York.  I talk to Dr. Henry Friedman, an expert on brain cancer.  He is co-deputy director of the Preston Robert Tisch Brain Tumor Center at Duke University Medical Center.  In addition to hearing about the latest treatments for the disease, you’ll see the secret behind how we do long-distance interviews for the CBS Evening News with Katie Couric.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


Click here for a musical take on over-testing.

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