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  • Accounting for the End

    Posted by Joseph Fouche on June 23rd, 2011 (All posts by )

    I’d like to thank the members of the ChicagoBoyz community for their condolences on my mother’s passing last month. They’re deeply appreciated. I’m comforted by the knowledge that she’s in God’s all-caring hands, that she’s free of mortal cares or sorrows, and that we’ll be reunited forever in God’s good time.

    One aspect of my family’s recent experience is worth sharing. It’s a data point of some interest to CB readers for many of the same varied reasons that bring us together here.

    My mother suffered three major bouts of breast cancer over the last 16 years. Her cancer was likely triggered, and exacerbated, by the hormone replacement therapy (HRT) she took for five years prior and ten years following her first cancer diagnosis. Recent studies suggest that HRT’s benefits are limited to treating one post-menopausal condition and then only for a limited time. Extended use greatly increases the risk of developing breast cancer. Mom’s 15+ years went well past any red line. She didn’t stop HRT until after the third, ultimately fatal, bout with cancer.

    Of the women in her family, my mother was the only one treated with HRT. There’s no prior history of cancer in her family. Grandma died of dementia at age 96. One aunt, just older than Mom, died of the inevitability being 5’5″ while remaining over 350 pounds for forty years straight. Mom’s oldest sister, the oldest of her five siblings, is alive and thriving at age 82 and only ever suffered one mild stroke.

    In her third, and terminal, bout with cancer, the cancer’s initial virulence and speed reduced Mom from vigorous sixty-something to frail seventy something in a mere two months. In fact, if not in chronology, she aged ten years in those two months. The cancer hit bone and rotted away a large swath of her pelvis, leaving her reliant on the walker that her own mother hadn’t needed until she was in her early nineties.

    Advances in cancer treatment managed to halt the cancer but couldn’t roll it back. This left Mom in a state of chronic terminal cancer, neither well or unwell but in the shadowy in betweens. She required regular chemotherapy to eke out even that quality of life. There was a cancerous lump under her left ear. When it reached a certain size, she knew it was time to go into the oncologist and receive another round of chemo.

    Chemotherapy is a debilitating treatment, one of those experiences in life that leaves you wondering if the cure is worse than the disease. This is not surprising:

    In August 1943, Roosevelt approved the shipment of chemical munitions containing mustard agent to the Mediterranean theater. On 18 November 1943 the John Harvey, commanded by Captain Elwin F. Knowles, sailed from Oran, Algeria, to Italy, carrying 2,000 M47A1 World War I type mustard gas bombs, each of which held 60-70 lb of sulfur mustard. After stopping for an inspection by an officer of the 7th Chemical Ordnance Company at Augusta, Sicily on 26 November, the John Harvey sailed through the Strait of Otranto to arrive at Bari.

    Bari was packed with ships waiting to be unloaded, and the John Harvey had to wait for several days. Captain Knowles wanted to tell the British port commander about his deadly cargo and request it be unloaded as soon as possible, but secrecy prevented him doing so.

    On 2 December 1943 German aircraft attacked Bari, killing over 1,000 people, and sinking 17 ships, including the John Harvey, which was destroyed in a huge explosion, causing liquid sulfur mustard to spill into the water and a cloud of sulfur mustard vapor to blow over the city.

    628 military victims were hospitalized with mustard gas symptoms, and by the end of the month, 83 of them had died. The number of civilian casualties, thought to have been even greater, could not be accurately gauged since most had left the city to seek shelter with relatives.

    This produced a curious side effect:

    Two pharmacologists, Louis S. Goodman and Alfred Gilman, were recruited by the United States Department of Defense to investigate potential therapeutic applications of chemical warfare agents. A year into the start of their research a German air raid in Bari, Italy led to the exposure of more than one thousand people to the SS John Harvey’s secret cargo composed of mustard gas bombs. Dr. Stewart Francis Alexander, a Lieutenant Colonel who was an expert in chemical warfare, was subsequently deployed to investigate the aftermath. Autopsies of the victims suggested that profound lymphoid and myeloid suppression had occurred after exposure. In his report Dr. Alexander theorized that since mustard gas all but ceased the division of certain types of Somatic cells whose nature it was to divide fast, it could also potentially be put to use in helping to suppress the division of certain types of cancerous cells.

    Using this information, Goodman and Gilman reasoned that this agent could be used to treat lymphoma, since lymphoma is a tumor of lymphoid cells. They first set up an animal model – they established lymphomas in mice and demonstrated they could treat them with mustard agents. Next, in collaboration with a thoracic surgeon, Gustav Linskog, they injected a related agent, mustine (the prototype nitrogen mustard anticancer chemotherapeutic), into a patient with non-Hodgkin’s lymphoma. They observed a dramatic reduction in the patient’s tumour masses. Although this effect lasted only a few weeks, and then had to return for another set of treatment, this was the first step to the realization that cancer could be treated by pharmacological agents.

    Chemotherapy agents have made striking advances in the last fifteen years. During Mom’s first bout and second bout with cancer, chemotherapy caused her to lose her hair. During her last bout, this was one side-effect she avoided. However, the other side-effects were still daunting if not as overt. Eventually Mom got tired of this twilight existence, trapped halfway between the pains of this life and the relief of the next and decided she would stop treating her cancer. And so she chose to die.

    Here is the aspect I’ll share:

    1. If you’re on Medicare and choose to risk death from your terminal cancer rather than undergoing treatment, Medicare will pay for hospice medical care in your home until your passing.
    2. It will not pay for treating your cancer if you choose to undergo treatment. Cancer treatment for the elderly is an out of pocket expense.

    This is why actuaries don’t get invited to parties. Such a policy is doomed to be personally tragic but actuarially rational.

    Mom was well cared for during the three months that passed between her decision to die and her death. The local hospice care provider did stellar service. As a family, we made sure to express our deep appreciation for the caring nurses aides who came out and cared for Mom every day in her obituary and at her service.

     

    2 Responses to “Accounting for the End”

    1. Michael Kennedy Says:

      When hospice was new, Medicare agreed to pay for it but, when hospice patients, through the benefits of the care, began to live longer than six months, Medicare threatened to cut off funding and force the hospice to refund payments. Just remember there is a big difference between private insurance and Medicare. Private insurance companies can be sued.

      When I was a medical student, I saw the first five year survivors of childhood leukemia at Chidren’s hospital of Los Angeles. It was astonishing. The parents had been told the child would die, usually within six months of diagnosis. I saw one child whose family had taken the prognosis very literally and had not educated the child nor ever disciplined him. He was a monster and the parents were asking the doctors when he would die.

      It is just anecdotal, Joseph, but I have found that women with skin metastases live a long time with the cancer in a sort of homeostasis. I don’t think HRT has been reliably associated with increased incidence but I do think it is dangerous to use after even for a woman in remission. I once saw this in a patient of mine. She was sort of a favorite. She was about 82 and used to tell me that if she was only 20 years younger, there might be some romance between us. I was 40. She was nearly ten years post mastectomy and was having trouble with atrophic vaginitis. She asked if I could give her some estrogen cream for it. There is no other treatment. She used it a couple of times and the cancer appeared as a thousand little nodules on her chest. It came back like a wildfire and nothing stopped it. I felt terrible. I used to sit with her at her place in Leisure World as she had no family. She died in a few months.

    2. Helen Says:

      That is too long for HRT, certainly. My very sincere condolences, if somewhat belatedly, as I didn’t know. For all sorts of reasons, that is a story I can particularly sympathize with.