How We Do Harm (8 page)

The scope is manipulated past the lesion and eventually to the ileocecal valve, the beginning of the colon.
On the way out, several biopsies of the transverse lesion are done though the scope.
Two are sent to frozen section to get a quick official answer to what the GI doc already knows.

Martin has a classic presentation of colon cancer.

*

AFTER
anaesthesia clears, Martin and his wife, Rae, are given the diagnosis.
Under the circumstances, the news is relatively good.
The lesion appears to be localized and could be excised surgically.
More often than not, a tumor is more advanced by the time it starts to bleed enough to cause anemia.

Eddie Ghosh, a surgical oncologist, is brought into the case.
He sees the patient, reviews the scans and the blood tests.
Using a plastic mock-up of the abdomen, he explains Martin’s surgery, adding that it needs to be performed sooner rather than later, so that a second cleaning out of the bowel will not be necessary.
Sooner, in this case, means late the next day.

The operation report, which would cross my desk later, tells a familiar story: a five-hour procedure, a long abdominal incision, isolation of the section of the colon with the lesion.
Then, trouble: the lesion protrudes through the bowel wall.

This is a sign of more advanced disease, pointing to the possibility of spread.
Resection of lymph nodes and the involved section of bowel was done without complication.
Visual examination of the rest of the large and small bowel, the abdominal wall, and palpation of the liver was normal.
Martin’s wound was closed, and he was taken to recovery.

Judging by the op report, the surgery was masterful.
This is how you do surgery for colon cancer.
The surgical oncologist biopsied the abdominal wall and looked for possible lesions on the liver capsule.
He even performed an intraoperative ultrasound of the liver to look for evidence of disease.

Things aren’t always done this well.
In the United States, a general surgeon trained to do hernia repair, hemorrhoid surgery, and appendectomies can perform colon cancer surgery, as can someone who has received extra training as a colorectal surgeon or as a surgical oncologist.
The latter two are more likely to do a better job.
In most cancers, the quality of the surgery is the most important factor in the ultimate outcome.
As one of my favorite surgeons, Charlie Staley, of Emory, likes to say, “You only get one chance to do the surgery right, so choose your surgeon well and pray you have an exceptional surgeon having an exceptionally good day.”

*

THREE
days after the surgery, Ghosh introduces Martin to Cameron Wilson, a medical oncologist.
The surgeon explains that Martin’s cancer went through the bowel wall and spread to six of the twenty-one lymph nodes that were excised during surgery.
That’s clearly Stage III.

Lymph nodes are like filters, Ghosh explains.
The cancer may have been stopped from spreading to the rest of the body by those filters, but a microscopic amount could have gotten past the nodes, which could result in spread to the liver or beyond.
Given this, some adjuvant chemotherapy would be necessary to clean up any small amount of cancer in Martin’s body.

Hence, Ghosh says, he decided to bring over Wilson.
“Dr.
Wilson is not just any oncologist,” Ghosh says.
“Dr.
Wilson is
the foremost
oncologist in north Georgia!”
It seems the two men know each other well enough for some good-natured teasing.

Ghosh is slight, short, dark-skinned, wearing a tweedy sport coat, but no tie.
He has a touch of a British accent and speaks faster than anyone Martin has ever met.
Wilson is almost unnaturally tall, reedy.
He wears a lawyerly gray suit and a light purple paisley tie.
His speech is as unhurried as a day on a North Carolina beach.

The class divide separating Martin from these men is vast.
Martin is a middle manager.
His job is to please others.
He doesn’t understand the medical terms (and some nonmedical terms) that have been thrown at him since his ordeal began.

Now, still weak and in pain in his hospital bed, he is getting presentations from men at the top of the medical profession, men who would generally be isolated from him by a cordon of secretaries.
Yet, there they are, just three guys talking strategy, like football players huddling before a decisive play.

Wilson’s plan is to give Martin a couple of chemotherapy drugs.
One has an odd-sounding, short name: 5-FU.
The drug will be given to him in single injections.
He will also get something called leucovorin, a folatelike vitamin that makes 5-FU work better.
The treatment will last for six months.

Also, Martin will get injections under the skin of a drug called erythropoietin, which builds hemoglobin, and a drug called GM-CSF, which builds white blood cells.
The first of these drugs will increase the number of Martin’s red blood cells, thus keeping him from developing anemia as a side effect of chemotherapy.
The second will strengthen his immune system.

Before Martin leaves the hospital, a catheter is placed into a vein under the skin on his chest, to make infusions simpler and less time-consuming.

*

BEFORE
he got sick, Martin, like most Americans, didn’t give much thought to big Washington issues such as the cost of health care.
Now these problems hit home.
Recuperation takes a long time.
Martin is weak, he has postoperative pain.
Even when times were good, Martin’s family lived from paycheck to paycheck, and now with his sick leave exhausted, Martin is too weak to work.

Sick leave runs out the same week Martin shows up for his first appointment with Wilson.
Martin still has his job, thank God, and the company still provides insurance, but without a paycheck, copayments on drugs and medical care will soon be ruinous.
His deductible is 20 percent on hospital and doctor services, with no coverage for outpatient drugs.

Coveting is not a human foible that afflicts Martin.
However, a powerful sense of not-belonging descends on him as he steps through the doors of Wilson’s office.
While the package-delivery service where Martin works is the picture of clean efficiency, this doctor’s office projects an aura of comfort and peaceful contemplation.
He walks past a gigantic aquarium and a small rain forest of tropical plants to reach the receptionist, who rises to greet him like a maître d’.

The receptionist, a pretty, young woman who speaks with a down-home drawl, leads Martin and Rae past a taupe, textured wall displaying an impressive collection of photos of Wilson standing next to various prominent Georgia politicians.
Sinking into soft velvet chairs beneath the oncologist’s wall of respect, Martin and Rae mindlessly fill out the usual forms, feeling out of place and wondering how they will pay for all this.

Before you get to see Wilson, you sit down with his insurance specialist.
As Martin and Rae sit uncomfortably in front of her desk, this well-mannered woman in a business suit opens a file and starts explaining how much the treatment regimen will cost.
This feels intimidating, like having to agree to a bank loan that you know will strangle you and your family.

Martin will be getting injections of chemotherapy five consecutive days every four weeks for twenty-four weeks.
Total estimated costs would be $30,000 to $35,000.
His copay, after insurance, would be $6,000 to $7,000.
The insurance specialist explains that the office will get reimbursed directly for the 80 percent due from the insurance company, and they want to work out a payment plan for Martin to cover the rest.

Martin admits that he is not sure whether he will be able to return to work and is worried about keeping his insurance while being treated.
Here, the lady says something about temporary disability, then something called COBRA, a temporary extension of health insurance after leaving one’s job.
“I don’t know much about these things,” she says.
“Perhaps you should see a social worker or a financial counselor.”

“Perhaps you can recommend one,” Rae asks.

“I am afraid I can’t.”

And that is that.

Wilson’s practice serves the elite.
Most of his patients are the wives of Atlanta’s business leaders getting adjuvant chemotherapy for breast cancer.
These women don’t work to begin with.
Their husbands are the breadwinners, and their insurance is linked to their husbands’ jobs.

After that meeting, Martin is ushered into a big room with twelve reclining chairs for the patients.
Each has a TV on a swivel arm.

Less comfortable chairs are next to the recliners.
These are for people accompanying the patients.
The patients are confined to the recliners for chemo administration.
Cancer patients have to get used to being sedentary for a long time; some regimens require up to eight hours of sitting.
Seven patients, some of them noticeably bald, sit with companions quietly watching TV or trying to sleep as fluids pump slowly from plastic bags into their veins.

A woman introduces herself as “Freda the Chemo Nurse.”
She starts telling Martin about the chemotherapy and how it will be administered.
They will push a needle into the port under his skin and run saltwater through it to hydrate him.
Antinausea medicine will go in next, followed by a bolus injection of leucovorin, followed by 5-FU.
(Bolus—the word means “ball” in Latin—is fast administration of a drug, a therapeutic blast.) The nurse goes through a litany of side effects, telling Martin what to expect at home in the middle of the night, what drugs she would recommend he take for those side effects.
This is a lot of information and a strange world.

Martin takes the chemo without difficulty and feels pretty good afterward.
As he and Rae get ready to leave, the nurse hands him a small wad of prescriptions that need to be filled at a pharmacy.
For a guy without coverage for prescription meds, this is a concern.
He is already trying to figure out how to pay for the chemotherapy at the doctor visits.

That evening, Rae goes to Walgreens and gets the scripts filled.
Total cost: $780.
She has to put it on the already abused charge card, not even wondering where the money will come from.
Martin knows this is not sustainable.
Should he just not get care?

Many American cancer patients have to confront the same dilemma.
Recently, the American Cancer Society found that one in four Americans undergoing cancer treatment had to put off getting a test or treatment.
Among people older than sixty-five, one in five said they had used up all or most of their savings in getting cancer care, and one in seven reported incurring thousands of dollars of medical debt.
The survey focused on over a thousand cancer patients and people whose family members have cancer.

Martin is open to the idea of forgoing care, but he has to evaluate it rationally.
This requires a talk with Wilson, not just about his finances, but also about his disease.
Martin needs his prognosis.

This is urgent: comparing the prognosis with and without chemotherapy is key to the decision to forgo treatment.
What is Martin giving up?
Alas, Wilson is hard to talk to.
During visits, he stops by and says hello as the nurse is readying Martin for 5-FU/leucovorin.
He never tarries long enough for Martin to get a word in.
Finally, Martin gives up and goes to see the lady in billing.

She is understanding and tells Martin that some people who have had money problems go to Grady.
It treats all residents of Fulton and DeKalb Counties regardless of their ability to pay.

Martin considers other alternatives.
He has seen commercials for Cancer Treatment Centers of America.
They claim to be a group concerned about supporting the patient emotionally.
Perhaps they would be more open to discussion than Wilson.
He calls them and over the phone learns that treatment there would cost even more than Wilson’s.
They charge extra for handholding, it seems.
He calls other places, and no one is willing to waive the 20 percent deductible.

Finally, Martin has to look at the Grady option.
To him, Grady is the county hospital where bums go.
It’s also where cops go after a shooting or an accident.
Burn patients are taken there, too, but outside of emergency care, it’s for poor folks.
It’s not where middle-class people—even middle-class people down on their luck—go.

A thought that Grady is where black people go crosses Martin’s mind, too, but he suppresses it, chastising himself for generating a racist, wrong thought.
He feels a tinge of shame at it.

*

MARTIN
has difficulty getting an appointment.
The administrative part of Grady makes him realize that he is dealing with a government organization akin to the Department of Motor Vehicles.

On the day of his appointment, he and Rae have difficulty parking in the garage next to the hospital.
After finding a spot, they get out of the car.
The garage is dark, with burnt-out lights.
It smells of urine, a big, semi-enclosed toilet for the bums.

They walk past the McDonald’s that is carved out of a corner of the garage.
They walk past people begging for money.
The Grady building itself is imposing, with brown granite running down the façade.
At the front entrance, the guards in blue uniforms are conspicuous.
Martin and Rae enter a grand but run-down lobby with high ceilings and displays from the history of Atlanta and Grady.

A series of news articles about an Atlanta native, Margaret Mitchell, the author of
Gone with the Wind,
is on display.
Mitchell was struck by a car and died at Grady in 1949.
Another series of pictures is of a fire that engulfed the Winecoff Hotel on Peachtree Street in downtown Atlanta in 1946.
It was one of the worst hotel fires in US history.
Another display acknowledges that Grady once ran two nursing schools, one for blacks, one for whites.

Martin and Rae find an elevator bank.
One of the doors is gold-colored (it’s bronze, actually).
A placard says it leads to the Georgia Cancer Center of Excellence.
Generally, places that are comfortable with excellence don’t call themselves centers of excellence.
Has anyone heard of a Princeton University Center of Excellence?
Memorial Sloan-Kettering Cancer Center of Excellence?