Covid Journal 6: Lung Cancer in the Time of Coronavirus.

My office practice has been slow here in North Carolina. I have been doing all of my patient visits via telephone, but even those are becoming rare. So I was glad when I got a call to see a patient with respiratory problems up on the wards. The patient herself was an elderly woman with an abnormal CT scan who had also undergone a test for Covid-19. Those tests are taking 8 days or more to come back unfortunately. Like many patients we test, it’s like that she would be discharged home before getting the results. Her doctor asked me to see her to see if the pneumonia they thought she had could be Covid-19. Looking at her CT scan I knew coronavirus was not the main problem, she had a lung mass which was probably lung cancer. 

In order to minimize our exposure time to infected patients many docs have been in the habit of calling in to the patient’s room to speak with the patient before entering the room for an exam. Impersonal yes, but probably safer. So picked up the phone and dialed into the room. As I pressed the phone against my ear I immediately regretted the decision. Thinking through the countless e-mails and meetings about Covid-19 preparation, I couldn’t think of one that mentioned anything about a phone sanitizer guy. Luckily I was bailed out by a busy signal. 

So I got up and walked over to the PPE station. This would be my first experience with PPE. Unlike NYC, New Orleans, and Detroit, Covid-19 is still new at relatively new at hospitals in North Carolina.

I had sat through a PPE demonstrations a few weeks  ago, there weren’t enough PPE for each of us to try it ourselves but I was pretty sure I got the jist of it. The process started with choosing a face shield or goggles. Apparently I’m a goggle guy. The patient was under droplet precautions, not airborne, which meant that the infamous N95 was not required, so I donned a surgical mask. Then it was the blue plastic barrier, finally gloves, and into the room I went. 

I’m always amazed at the resilience and courage of so many people when they hear that they have cancer. I do the best I can to be in the moment with them, there’s tears, touching, hugging, prolonged silence, questions, and more tears. It must be especially hard being told of this in such an impersonal matter. Our words competed with the loud device that recycled the air. As I hugged her I was somewhat self conscious about how it must feel through the cold shiny plastic that I wore. There was no way for her to see any of my expressions, my smile, my magnificent smile that everyone always compliments me about. I usually offer to call family for patients to help explain the diagnosis to them in the presence of the patient. I offered the same to her, but then I realized that taking out my phone would violate precautions, so the call would have to wait. 

I left the room, and was immediately met by a spotter who guided me through the doffing process. As I went through the steps I started thinking about what had just transpired. Covid-19 has just arrived and will be with us for at least several more months, if not longer. Lung cancer, too, is not going anywhere. I need to get better at this. 

End of Life Conversations are Becoming End of Life Confrontations

“How Dare You!”

Life can change in a heartbeat. Most of us believe that our lives, our loves and all the that things that make us who we are is a gift from a higher power. One that can be taken away as swiftly as it is given. But somewhere in the shuffle of taking kids to practice, catching up on emails, worrying about bills, and the search for the perfect barbecue, it’s all too easy to forget the truth of life. The one truth. The one single thing that life guarantees each and every one of us. From the moment we take our first breath,  life makes to us but one promise. The promise that our life will someday end.

“Who do you think you are?”

For some of us, death comes after a lifetime of achievement, for others all too soon. For many it will be feared, for others it will be welcomed as their bodies wither away. But for more and more of us in our increasingly sterile and safe society, it is simply not to be thought of at all. An unwelcome stepchild locked tightly away in the attics of our consciousness. Like a demon in waiting, we reshape it, remake it, remold it, until it becomes an ever distant sunset that bookends a romantic dream of a life full of love, accomplishment, achievement.

“You have no right to say that!”

Until finally, that inevitable day approaches. A man or woman in a white coat tells you the terrible news that your loved one is passing away. That yes,  they are alive and can be kept alive, but there is practically no chance that they could recover. They will never go back to the person they were before.

“Where’s my regular doctor?” Continue reading “End of Life Conversations are Becoming End of Life Confrontations”

What You Need to Know About Electronic Cigarettes

Electronic cigarettes are here, settling over the country, quite literally,  like a fine white fog.  Smokers in turn, have been turning to them as a tool to help them quit, though the device manufacturers are are not allowed to market them that way in U.S. It seems intuitive that a device that mimics the action of smoking but without the combustion and smell of burned nicotine would be an ideal nicotine replacement therapy. However, there remain precious little research about weather the fine white smoke they deliver is as harmless as a morning fog, or as dangerous (and unwatchable) as an Oregonian fog delivering the vengeance of tormented souls.

E-cigs’ popularity can be attributed to the fact that they deliver an experience that very closely mimics the act of smoking, minus the social banishment that comes with exhaling obnoxious smelling carcinogens into other people’s personal space. How do they accomplish this seemingly impossible task? Why through the magic of modern technology, of course!

E-cigs look much like a regular cigarette, they are puffed on in the same way, give off a vapor that looks like smoke and even have an LED light that mimics the combustion of nicotine. The devices are made up of several components. In place of the body of the traditional cigarette, there sits a rechargeable battery housed within a cartridge which is capped on its end by an LED light. Where the filter would usually be on a traditional cigarette, there sits  a heating element/atomizer as well as a replaceable nicotine cartridge. It is within this cartridge where a liquid mixture of nicotine, flavoring, and propylene glycol sits. Propylene glycol is a food additive that is also  used to create the “fog” in fog machines. The cartridges can be obtained in varying strengths of nicotine all the way down to zero.

When one puffs on an e-cig, the sensor activates the LED and the heating element which then atomizes the fluid in the cartridge, delivering a dose of nicotine and vapor. The main perceived safety advantage of this mode of nicotine delivery has presumed to be the lack of combustion of nicotine, which by itself creates a host of toxic chemicals. The nicotine itself is still delivered, however, with its resultant deleterious effects.

There remain a number of things which are not well known about e-cigs. While propylene glycol appears to be safe in other applications (it’s an FDA approved food additive), it is uncertain as to how inhaling it regularly affects the lungs.  It is also uncertain how efficacious e-cigs are when used the way that many people appear to be using them, as a smoking cessation tool.

To that end researchers in Italy conducted a study in which they enrolled 300 smokers who were not interested in quitting and were otherwise healthy. They were randomized to using e-cigs at either a steady dose of nicotine, a decreasing dose, or containing no nicotine at all for 12 weeks. They were allowed to use the e-cigs as they liked in addition to regular smoking and they were not  encouraged to quit smoking regular cigarettes.  After 1 year, quit rates (for all nicotine including e-cigs) among those using nicotine containing e-cigs were 11%. While this may not seem like a lot, it is as good as or better than most current nicotine replacement therapies. Keep in mind that these were people who were casually smoking e-cigs without the intention of quitting. Among those who did not quit, the number of cigarettes smoked daily decreased from 21 smoked per day to 14.

The investigators also looked at adverse events in order to gauge safety. They found that commonly reported adverse events actually decreased from baseline over the course of the study. They also found that side effects commonly seen during  smoking cessation trials such as hunger, insomnia, irritability and depression, were infrequent, nor were there any significant changes in weight.

This data appears encouraging that e-cigs do have some use as a nicotine replacement therapy, and that many people could actually quit without simply exchanging one addiction for another. It also appeared that, at least over the duration of the study, the e-cigs appeared safe. People appeared to have less side effects, probably owing to the fact that they were smoking fewer traditional cigarettes.

However, this short 12 week study can not tell us about long term effects of e-cigs. Nor does it address other pertinent questions. Such as the moral hazard of removing social stigmas. Many who use e-cigs do so with the thought that they can use them in places where regular smoking is not allowed.  One could wonder whether these products could take us back to the days of Don Draper,  when it was permissible to smoke in public places, or even on the job, unwittingly leading to greater smoking rates. Some argue that the ability to flavor e-cigs will further draw younger people to smoke, likely made worse by an incorrect perception that, since they are not cigarettes,  e-cigs are “safe”. Yet another problem is the consistency between products themselves. There exists a significant variation between contents of e-cigs between different makers, making it difficult to judge whether findings about one product can be generalized to others.

Indeed, we are only at the beginning of determining the risks and benefits of e-cigarettes. While they do appear to have some promise as cigarette smoking cessation tools, there remain several hazards to their increasing use. Until we have a better idea of what exactly is in this increasing fog, we best proceed with caution.

Citation: Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, et al. (2013) EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as Tobacco Cigarettes A Prospective 12-Month Randomized Control Design Study. PLoS ONE 8(6): e66317. doi:10.1371/journal.pone.0066317


Lung Cancer Screening: Almost There . . .

In 2011 The National Cancer Institute published results from their study of low dose CT lung cancer screening of individuals identified as at risk for lung cancer. The investigators enrolled those between 55 to 74 years of age who had at least 30 pack years of smoking under their belt (number of packs per day multiplied by number of years smoked). These people were then randomly assigned to either a chest x-ray group or a “low dose” CT scan group, with 3 images over 2 years. There was initial criticism that the authors used chest x-rays as the control rather than “usual care”. However given that the PLCO trial, comparing chest x-rays to usual care, subsequently showed no difference between the two, this would appear to have been a sound strategy.

The study also received some well deserved praise, as it was the largest study of its kind, and demonstrated some very impressive findings, as detailed in the article’s abstract. The most striking findings were:

  • a 20% reduction in the risk of death from cancer relative to the control group.
  • a 6.7% reduction in the risk of death from any cause relative to the control group.

I cannot sum up how to you how astounding these results were/are to the medical community, specifically to those who are involved as patients, or in the treatment, diagnosis, support, research, and  fund raising of lung cancer. Continue reading “Lung Cancer Screening: Almost There . . .”

CT Lung Cancer Screening, Star Trek 3, and Other Disappointing Things

Will the The Needs of The Many Outweigh The Needs of The Few?

That was the axiom a dying Spock posed to Captain Kirk just after he saved Kirk’s behind (again). Well in that case, (spoiler alert),the needs of the many did outweigh the needs  of the few. . .until they didn’t (if you’re really curious watch Star Trek 3, or better yet, don’t and just take my word for it). Curiously, I wonder if things will unfold in a similar fashion in regards to findings reported by the National Cancer Institute in its CT lung cancer screening trial published last June in the New England Journal of Medicine. Continue reading “CT Lung Cancer Screening, Star Trek 3, and Other Disappointing Things”