Narrative Medicine

Measuring Outcomes: What the Newly Diagnosed Should Know

I open this post by offering key definitions that are helpful to anyone impacted by a cancer diagnosis, directly or indirectly, which speaks to nearly half of the population of the United States. Indeed, “Approximately 38.5 percent of men and women will be diagnosed with cancer of any site at some point during their lifetime” (reference). I explain the standard metrics for monitoring cancer response to treatment, and I discuss the role of these metrics in determining the standard of care protocol. I conclude with a discussion of the cancer experience that is not so easily quantified, or captured by the established metrics. My aim is that in this article, persons relatively new to the cancer experience may find tools to better equip their journey. The National Cancer Institute (NCI) offers a similar resource on understanding cancer prognosis (here).

 

Standards of care for treating cancer—that is, the established “protocols” for how, when, in what sequence, and guidelines for determining dosage, vary by cancer type, yet for at least 50 years, the general cancer treatment program is colorfully, if not cynically, called “slash and burn,” referring to the twin procedures of surgery and radiation therapy. Or, “slash, burn, and poison,” when cytotoxic (cell-killing) chemotherapy agents are ordered following surgery and radiation. The new era of “precision medicine,” which employs highly specialized treatments engineered to target the biological characteristics of a person’s cancer, promises to discard this primitive slash, burn, and poison program, but to date, hugely successful outcomes that result from targeted therapies in trial for quite specific cancers have failed to be borne out clinically in the general cancer patient population. In short, for all the hype of precision medicine, day-to-day treatment protocols across the country maintain the status quo.

 

The aim of any treatment protocol is to offer the therapy, singularly or in combination with others, that is most likely to produce the greatest degree of therapeutic efficacy, or “disease response.” Therapeutic efficacy, disease response, is measured with sophisticated diagnostic imaging tools such as MRI, CT, or PET scans. The overarching therapy effectiveness metric for cancer types is quantified by median overall survival (OS), meaning the time after diagnosis when half the measured population has died and the other half is still living. Median progression free survival (PFS) offers a similar metric quantifying the time following diagnosis that half the population has experienced disease growth or recurrence and the other half has not. Take my case, glioblastoma, with a median OS of roughly 15 months (reference). This indicates that 15 months following diagnosis, half of the diagnosed population is no longer living, and half of the population is continuing to live. My current time since diagnosis is today (August, 2017), 15 months out, meaning statistically, half of those who were diagnosed around the same time I was have since passed away. Some died very quickly after diagnosis, and others will live three, four, five, sometimes six or eight years longer. Of course I aim to be included in those outliers showing long-term survival of five or more years.

 

Protocols are tested against current standards of care, typically in randomized control trials, to measure OS and PFS against the current medians for the standard of care. Regulatory bodies, the Food and Drug Administration (FDA) for example, approve drugs, devices, and procedures, when those therapies increases either OS or PFS for the trial population above the current standard of care, without an intolerable side effect profile, or increased toxicity. Trial therapies that perform better than current standards, or when no current standard is established, have a likely chance to be approved. Sustained improvement in key metrics over time, reported in longevity studies, meaning spanning long time frames, or meta-analyses, meaning spanning large and diverse populations, may lead to a revision or new standard of care for a cancer type that is treated by the newly approved therapy.

 

In short, the standard of care is established for umbrella categories of cancer types based on measuring the same key metrics across large populations over a long period of time. Those therapies, or combination of therapies, that maximize OS and PFS, while mitigating toxicity are selected as the ongoing standard of care.

 

The politics of drug discovery and approval involve governmental regulatory agencies, multi-billion dollar pharmaceutical industries, and culturally embedded research paradigms. That is all too much to thoughtfully discuss in this article. I will say only this: reimbursement drives the systemic treatment of cancer. Standard of care therapies are typically covered by health insurers, but many experimental treatments or so-called “off-label drugs,” that is, drugs approved in the treatment of one disease that show promise for treating other diseases but are not yet proven in randomized control trials, often are not covered by insurance. Relatedly, the genomic sequencing that is required to determine the appropriate “precision medicine” to target a person’s specific cancer variant is currently not covered by the majority of health insurers.

 

Standard of care offers patients the protocol with the statistically demonstrated best shot at long-term survival. Standard of care is also the protocol commonly covered by insurance. On its face, this is a good thing that insurance covers the standard of care for a disease, but there is at least one downside. This schema ties patient treatment options to governmental budgeting priorities and big money lobbyists. In a purely hypothesized scenario, but not one divorced from reality, if a lawmaker hears from her lobbyist from big pharma that disease X is well controlled with approved treatment Y, then the prospect to increase funding to the National Institutes of Health (NIH) may appear less pressing to the lawmaker who sees little reason to pay the big price tag of experimental research, when the lobbyist is showing their company’s success rates. This introduces a feedback loop where the government fails to fund research, insurance companies have little reason to reimburse experimental therapies, and patients are offered fewer options to explore cutting edge therapies. It is for these reasons that I advocate for increased research funding for the NIH, its subsidiary arm, the NCI, and not-for-profits, like the National Brain Tumor Society (NBTS) who equip persons affected by brain tumors to raise their voices to lawmakers who may only be hearing one side of the experimental research budgeting issue.

 

Taking stock, so far I have roughly defined key metrics put in service to monitor the effectiveness of our treatment protocols, I have explained how these metrics are used to revise standards of care, and I have revealed one issue with our reimbursement-driven healthcare system, namely, that it serves as a barrier to funding trial research. Now, I turn my attention to the experience of illness—something not easily reported by standardized metrics. To resolve this issue, patients must learn to tell their stories! The fields of medicine and pharmaceuticals are becoming more interested in something called patient reported outcomes (PRO). These PRO metrics speak to the quality of life impact given a selected treatment protocol, but constructing a narrative, with the support of friends, family, and trusted clinical practitioners, is the best way for a patient to share their experience with lawmakers and medical teams to serve as a catalyst for change—whether the change is to ask congress for budgeting priorities or frame a conversation with a patient’s clinical specialist.

 

Harnessing the power of story telling can also be a powerful tool to communicate with loved ones who struggle to know how best to respond to the illness experience.

 

I disengaged my friend group at each of three milestones in my life: first, when I started grad school, I lost friends to my study commitments; I picked up an evening job in the service industry to help care for my kids during the day, attend class in the afternoon, and bartend for income at night. Second, when my wife and I grew our family by having kids, my friends were mostly grad students and bartenders, not the most family-friendly groups, and adjusting to family life created a rift in some of these relationships; third, when I was diagnosed with aggressive and incurable brain cancer.

 

I cancel on friends often: dinner plans, concerts, hanging out to catch the Cubbies play, I cancel these plans all the time. Sometimes because I am fatigued, sometimes because I know the environment will trigger a focal seizure, or at least bring on seizure-like symptoms: left-sided numbness, light-headedness, dizziness, and headache, or for what has been the case recently, I cancel because I just want to be home, with my wife and kids nearby. Brain cancer has dynamically changed my relationship with my wife. The emotional burden we carry cannot be overstated. The metrics, the open trials, morning email bulletins from medical news outlets all twist and turn their way through my mind each day. My wife works hard in a trauma hospital to support our family, to be the only driver in our home to get each of us in our family of five to where we need to be, to carry our family’s medical benefits, and she manages our monthly budget. She and I are both exhausted. She needs more sleep than she gets. I need support from friends who understand, but with a disease incidence rate of three in 100,000 and only 5% of the diagnosed population living five years, it is difficult to find a friend locally who shares my diagnosis, and among my non-cancer friends, it is tough to find one who not only listens, but who understands. I look for emotional support from my wife, which places yet more burden on my care partner to fulfill multiple roles in my life.

 

I read, write, and research daily, fearing that I must approach my “work”—blogging, public speaking, working on a manuscript, with urgency because the course of my disease, or the effects of the treatments to control the disease, in time will negatively impact my higher level cognitive functioning. Here I am, a head full of medical knowledge, self-imposed restrictions on having pizza and beer, pretty disengaged from new music, sports news, and pop culture, and never much wanting to do anything other than do each day only those things that contribute to the big goals I set out for myself before I reach my dot on the overall survival normalization curve.

 

Practicing how we construct our stories to communicate these emotions, decisions, and reactions in a way to inform our friends and family and not alienate them is an acquired skill that will take each person impacted by a cancer diagnosis, directly or indirectly, some time to cultivate. It is my hope that equipped with the language in this article, and the glimpse into my personal experience, you may find your attention to these issues more focused.

Making Sense of the Senseless

A classic sketch featuring Dana Carvey as Tom Brokaw aired on Saturday Night Live in 1996. The comedic premise has Brokaw (Carvey) pre-taping former President Gerald Ford obituaries to “cover all contingencies,” while Brokaw prepares to spend the winter in Barbados, presumably then unavailable to cover breaking news. Brokaw is reporting the fictional/possible “Gerald Ford shot dead” story, when his producer prompts Brokaw to include the word “senseless” (marker 1:10 in the linked video). Brokaw reports, “Gerald Ford shot dead today at the senseless age of 83”; the crowd erupts in laughter.

Of course it’s not the age of former President Ford that is senseless, but his assassination. This post is not on the mechanics of humor, but there is something instructive about this joke, grounded in what we mean by “senseless.” President Ford’s age is easily accounted for, and not something arbitrarily assigned to the President. Indeed, we could verify the President’s age by examining evidence such as the year recorded on his birth certificate. What we could not account for are the motives, thoughts, and attitudes of the imagined assassin. Hence, it is appropriate to say, “shot dead, senselessly,” rather than, “senseless age of 83.” Brokaw’s inappropriate insertion of “senseless” upon the producer’s request plays as a joke about language and about the “thoughtless anchor” trope, who only reads the prompter but, in some sense, does not know what they are saying. (For another salient example, see Will Ferrell’s Ron Burgundy in Anchorman, “Go fuck yourself, San Diego,”)

Senselessness in the context of Carvey’s Brokaw cashes out as some feature of an event or thing that we cannot account for. It is inexplicable. It confounds us. It is senseless. Someone’s reported age is not senseless. The unlikely assassination of a former President is senseless. Let this be a stand-in definition for ‘senseless’: something for which an account cannot be given. Hopefully I have provided adequate motivation to pick up this concept and apply it. Regardless, nothing all that important turns on the definition we settle on for ‘senseless.’

My loved ones identify senselessness in my glioblastoma diagnosis. There is no known cause for glioblastoma. There is no known cure for glioblastoma. This characterizes the disease as a double whammy: no prevention and no cure; utterly senseless. Adam was diagnosed with glioblastoma at the senseless age of 34.

Fortunately, we are not doomed to senselessness. We can see our way out of it by appeal to a recurring theme on my blog: narrative medicine.

Read the following description of one responsibility of clinical practice from Arthur Kleinman, quoted in Dr. DasGupta and Dr. Charon’s article on personal illness narratives[1]: “Rather than technical adherence to any strict format of history taking, empathetic witnessing involves ‘the existential commitment to be with the sick person and to facilitate his or her building of an illness narrative that will make sense of and give value to the experience'” [emphasis added].

Kleinman’s claim, endorsed by Drs. DasGupta and Charon, prescribes that clinicians are assigned the task of helping persons under their care to construct their narratives, that is, to tell their stories, and in so doing, to find sense in the circumstances and by some measure render the experience valuable.

I floated an analysis of ‘senseless’ to be an event or thing that cannot be accounted for. If you get on board with that definition, then making sense, as Kleinman orders, of the senseless, involves giving an account for one’s circumstances. Easily done, maybe, when you pick out your own agency in a circumstance, but with so many cancers generally, and glioblastoma, particularly, there is no accounting for the disease and no role for personal agency. Personal agency features heavily in our acceptance and moving forward with the diagnosis, but causally, pre-diagnosis, there was nothing I could have done to prevent my brain cancer; this is what I mean by no role for agency. The circumstance seemingly remains senseless. Is there another interpretation on offer? I suggest an alternative.

Rather than seek meaning in the senseless, a Sisyphean task, as I have said, there is no accounting for glioblastoma, what if I were to recast the circumstances in a new way, not as Adam with brain cancer that has no cause and is thereby senseless, but let us examine the outcome, when I interpret the circumstances as Adam, the graduate-trained philosopher, nearly ten years of experience training, consulting, and facilitating organizational change management in professional settings, with a supportive family, a strong social network, and relatively unimpaired cognitive functioning relative to this stage of his disease, save for his neuro-fatigue, seizures, headaches, frequent breaks, etc. On this revised reading of my circumstances, I have done nothing to change the constants that are included in the story–I still have brain cancer; there still is no cure, but I recast the circumstances in such a way to mitigate the threat of those things for which we cannot account.

There is no accounting for glioblastoma, or my having the disease, that is all senseless, confounding, inexplicable, but there is a way to tell my story, to construct my narrative, that makes sense of things, or at least better sense of them than I possessed pre-reflectively. I repeat for emphasis: I recast the circumstances in a way that made sense, in such a manner to mitigate the threat of those constants that are senseless. We may infer from Kleinman’s direction that making sense aids the storyteller in finding value in the experience. What I have done here in a few short paragraphs that reflect my many months wrestling with my disease, is to set aside those things for which I cannot make sense. I allow the disease, and my having it, to be senseless, but as Kleinman orders, I can make sense of and find value in the experience. More accurately: I distinguished the particulars that make up the experience from the experience itself. Some facets of my experience, the cause of glioblastoma, for example, are senseless, but my illness experience is much, much greater than the diagnosis.

I penned an open letter to Senator John McCain last week, on the heels of his glioblastoma diagnosis. I received countless article comments, tweets, and emails. One email related the story of a person whose dad died from glioblastoma when this person was still a child, only 12 years old, too young to understand the complexities and difficulties of daily living with brain cancer. This person, then child, emailed to tell me that my letter of advice and support to the Senator helped this person to better understand what life was like for that person’s father. By constructing my narrative in new lights, lights seeking to shine brightly on the experience that can be made sense of, allowing the senseless particulars to remain as part of the experience, but their threat mitigated, I found value in my experience by sharing my story with others.

We find sage advice at the intersection of comedy and medicine. Unsurprisingly. These both are unique expressions of humanity. Comedy and medicine are experiences far greater than the particulars that make them up.

Clinicians and professionals aid a person in crafting their narrative with the purpose of distinguishing those things for which we cannot account from the experience itself, when performed successfully, sense can be made of the senseless, and value can be found in the experience, even an illness experience, but just like comedy, we get better with practice.

 

[1] DasGupta, Sayantani, and Rita Charon. “Personal illness narratives: using reflective writing to teach empathy.” Academic Medicine 79, no. 4 (2004): 351-356.

(Adam’s) Narrative Medicine

Tomorrow, Wednesday, April 12, I will pull a chair up to a table in the Medical History room in the IU School of Medicine, Medical Library. I join ten others–nine students and the professor, who are studying Narrative Medicine this semester. Consider this the preamble. In this post I rehearse my talking points, and I emphasize the importance of storytelling in medicine

Many of you following my journey recognize that I have been sharing my story for several months by way of social media–Facebook Live, this blog, monthly twitter chats (#BTSM), speaking in community settings, in academic venues–Marian University College of Osteopathic Medicine; this upcoming public lecture hosted by IUPUI Religious Studies Department on April 19, and perhaps more important than each of these are my regular coffee conversations with close friends and former colleagues, sometimes one-on-one, sometimes in groups.

Here are two theses, hypotheses maybe, which have always been there, just beneath the surface of my areas of interest, motivating continued study.

  1. Story telling is a long-honored and integral piece of our human experience. The content that comprises our stories vary widely by cultural traditions–and with respect to our friends who study myths and tropes, perhaps the content across cultures is not tremendously different, after all (consider flood and creation stories traced easily to many cultures to emerge from the Mesopotamia), but the point I wish to make here is more broad. The act of sharing our experiences, framing our narratives, and contributing to an oral tradition is a defining feature of our collective humanity, at large, and certainly features of our identification with a community or, more abstractly, a peoplehood. But this stands against the following, second hypothesis.
  2. We seek an objective worldview, so far as we think it is possible to achieve. The Western academic tradition employs the language of mathematics to describe the world on purely objective terms, purportedly void of subjective interpretation; physicists seek, through reductionism, the outlook that meaningful explanations are sought after only at the bottom-most level of the explanatory target: the level of fundamentality. That at some most primitive level the discrimination of distinct objects dissolves and what remains are, well, not even objects at all, but a collection of attributes, charge, mass, spin, and so on that stand in relation to one another.

These theses stand in seemingly stark contrast to one another: on the one hand, the anecdotal, narrative, story telling accounts, passed from family to family, friend to friend, peer to peer; multigenerational. These stories contribute the to a sense of community and the reinforcement of values indicative of exemplars borrowed from the community who now live on as the subjects of their celebrated narratives.

On the other hand, the objective, quantified worldview has little concern for the subjective reinforcement of values drawn from a community of origin, and instead is concerned chiefly with predicting outcomes from a set of initial conditions and governing principles. Given reductionism, determinism, and fundamentality, the evidence presented to us by contemporary physical theories are, by definition, stripped of subjective identity.

Where does the physician find herself? Her patients, flesh and blood; her recording of their symptoms locked behind a protective wall erected from the scaffolding called HIPAA. Our office visits call out for personal connection. Our medical record keeping warns against privacy breaches.

Is this the space–the gray area between the practice and the policy, that we find narrative medicine? Between the stories and the statistics? The physicians and the patients. Medical history gathering is the pathway through which the two may become connected. Especially for the chronically ill, the cancer survivor, the terminally diagnosed, that more so than in any other space physicians and patients are presented with the opportunity to recapture the first of my two hypotheses. That storytelling is attachment to a community, through that which medical school may drive a wedge; may serve to detach physicians from their patients; detach specialists from the bodies on which they specialize. The community can be rebuilt when we seek to remove the barriers the lead to detachment. When healthcare is viewed not as physicians and patients–two separate classes, but as members of a medical community, where medical professionals are accountable for the care they provide, and patients are accountable for investing in their health and wellbeing by taking seriously the relationship with their caregivers.

Like great storytelling, the hero of our narratives, the reinforcement of personal values we experience when seeking solace in our favorite stories–what Rita Charon calls the “sense of story,” might we find the strength to craft our own narrative, featuring ourselves at the center, and refusing to settle for medical professionals who are not compelled to listen closely while we tell our stories.

Wednesday, April 12, I will tell my story again, for the n’th time, but for the first time. It will be told to a room of strangers, yet, when our time together is over, the influence we have over each other will linger. This is only possible when we recognize ourselves in others, when we eliminate barriers erected in the name of responsible detachment to practice objective science and medicine, and we do this through the art of storytelling.