Among lessons learnt from her past two walks with cancer, one is if you enter the initial conversation about conventional therapy unprepared, the names of the drugs alone will overwhelm your mind, leaving you little capacity for any clarity with decisions or meaningful questions.\u00a0 Audio recording for review or not.\u00a0 Faced with more complexity than the mind might want to critically think about under the pressure of time, among other pressures, thoughts can get hazy.\u00a0 And as the internet will reveal, when faced with such complexity, avoidance is gratifying and patients can easily be drawn to attach themselves to simpler arcs of cancer quackery, like juicing raw calf liver; or something more palatable, like orange juice.\u00a0 I desire to deeply understand options we encounter.\u00a0 Futile or pointless, one may argue.\u00a0 But a desire nevertheless.<\/p>\n
A doctor with patience might attempt to simplify to the unprepared, which ultimately leads to reductionism.\u00a0 I do not envy the job of a good oncologist (or any doctor for that matter).\u00a0 Or should the patient leave the choice, which might be a choice among multiple choices, purely to the doctor?\u00a0 Doctors are human too, and I respect the incredible depth of character required to be able to maintain emphatic listening over a busy day.\u00a0 But to make such choices tailored to an individual versus a routine plan, in a span of minutes, when there is no true “fix”?\u00a0 The routine plan wins in general, I would wager, as much as our idealistic desires expect us to be our doctor’s sole patient.\u00a0 And the default routine might not be the choice for you.\u00a0 Perhaps it was the experience of having a top rated doctor, perhaps more interested in other research, who saw your wife’s second little regional occurrence as an inconvenience to her day, who dealt her a potentially flippant plan.\u00a0 One which leaves other doctors today curious, as to why no further investigation or adjuvant therapy was done.\u00a0 We’ve been fortunate to now have as good a doctor as we think she is, and one that we like.\u00a0 One that shows empathy despite language barriers.\u00a0 So given the tireless workload the doctors seem to carry at this cancer center, the least I could do was to be prepared to listen well; and take responsibility in conversations with her, instead of tangential questions like, “How about orange juice?”<\/p>\n
We were called into the room to await Dr P, the oncologist, and I resisted the itch to walk over to the pathology report screen to peek.\u00a0 The incredibly efficient set up for the doctors here tend to be as follows.\u00a0 They consult in two adjacent rooms.\u00a0 While they are in one, nurses set up the other room for the next consult.\u00a0 Desks neatly back to some determined layout, coffee refilled, and patients’ charts pulled up on 4, yes four, 21-inch monitors.\u00a0 Two vertically oriented ones showing imaging, the third with patient summaries, and the fourth for notes and the latest lab report.<\/p>\n
What did the small print read?<\/p>\n
“You look good.” echoed Dr P, smiling at Annie as she sat down.<\/p>\n
After a quick follow up on current symptoms, she went straight to the biopsy results.\u00a0 ER+(8), PR+(4), Her2-, Ki-67 30%.\u00a0 The Ki-67 puts the subtype currently into luminal B (her2-).\u00a0 She articulated that it was a good report, in the sense that it would allow us the options of endocrine therapy.\u00a0 She proceeded to discuss implications and options, in a partnership manner, like she said she would in earlier consults; even if the options were of a rather standard protocol, given the biopsy.\u00a0 It came to choices of goserelin plus an aromatase inhibitor (letrozole), goserelin plus a hormonal drug (fulvestrant, a SERD), oral chemotharapy (capecitabine), or some clinical trial.\u00a0 The goserelin is effectively used to put a pre menopausal woman into a post menopausal state.<\/p>\n
We’d rather not start with chemo, and she agreed.\u00a0 So it was one of the first two.\u00a0 Her experience with breast cancer in younger women inclined her towards the second.\u00a0 There was a pause, and we asked her about adding palbociclib to the fulvestrant.\u00a0 The combination was recently fast track approved by the FDA in the USA after the PALOMA3 trial, which included pre\/peri menopausal women, and showed a median doubling of progression free survival.\u00a0 “Ah!” she smiled.\u00a0 Turns out, Korea was one of the countries that had participated in the trial, and Dr P had patients in the trial.\u00a0 It had just been approved for use in Korea, two days prior to our consult.\u00a0 She briefed us about the experiences she’s had with patients on it, and possible dose adjustments needed for Asian women.\u00a0 There was one small catch.\u00a0 The drug was not yet in circulation in Korea outside of the trial.<\/p>\n
Initiative and action took effect. She talked to the nurse, and picked up her cell phone right then; calling hospital administration, who sent someone over; and also called a contact at Pfizer Korea directly about it.\u00a0 And told us if we could wait, she’d let us know about getting the drug in.\u00a0 We covered other questions we had around goserelin (Zoladex) dosing; and the bisphosphonates she would continue with versus denosumab.\u00a0 The hospital has its own genome institute, so she would also be sending tissue for genome sequencing.\u00a0 We went back outside to wait as she completed the rest of her day’s consults.\u00a0 The corridor still filled to capacity with patients.\u00a0 We had a dinner appointment at 7pm with A (KP’s wife), who was in Seoul for work from Singapore.\u00a0 KP had visited a few weeks ago.\u00a0 7pm had initially seemed like a reasonable time to plan dinner, given that 2:30pm was the last appointment we had.<\/p>\n
Two hours later, we saw Dr P again, probably as the last patient of the day.\u00a0 She was kind to note, “You waited a long time.”\u00a0 The hospital will attempt to work with Pfizer Korea to expedite bringing the drug in, within 3 weeks, from wherever stock is available, either US or Germany.\u00a0 The timing actually works out, she noted, for Annie to start goserelin and fulvestrant first.\u00a0 This allowed for the second radiation of the spine (C7-T1) to begin and complete before palbociclib in added.\u00a0 Annie and Dr P had a moment of between them, commiserating the size of the Zoladex shot and counting the total number of shots she’d be getting monthly, starting that very day (fulvestrant was two shots).\u00a0 You never really forget the size of a Zoladex needle<\/a> after seeing one in person.<\/p>\n It was nearing 6pm, when outpatient departments close, as we left her office.\u00a0 We had order sheets for pain meds at the pharmacy to pick up, and for the shots to be done.\u00a0 Frenzy ensues.\u00a0 Nurse J from the international health clinic happened to come by to pass us printouts of blood tests as well.\u00a0 Timely.\u00a0 It was helpful for me to have her navigating the pharmacy process before close.\u00a0 Simultaneously, Annie went into another room to get instructions about her shots and sign acknowledgements.\u00a0 Nurse J headed off after helping me, and I walked back to find Annie, quietly relieved that our friend A had sent a message to indicate that she would be late to meeting us for dinner.<\/p>\n Complications arise.\u00a0 If only things would always “just work”.\u00a0 Being the foreigners, and being the first to get a particular medication at the institution probably messed with standard processes somewhat.\u00a0 Turns out the nurse in charge of the paperwork for the various drugs was not fully in sync with Doc’s suggested process for the palbociclib.\u00a0 The form she prepared for Annie to sign was for ordering it through the Korean government’s Rare Medications center.\u00a0 Which requires a bank transfer upfront prior order, with the center dong the order after.\u00a0 This would become a monthly bank transfer, to a government agency, without an invoice\/receipt, at about USD $500 per daily pill.<\/p>\n We doubted the possibility of insurance claims with such a process, even if we could get approval to have the drug covered.\u00a0 Language barriers were starting to introduce challenges.\u00a0 I turned, left the room, and ran, hoping to catch Nurse J before she left for the day.\u00a0 I recall noting my dwindling mental acuity as I ran; instead of leaving items with Annie, my backpack flopped half zipped on one arm, a pack of pain meds still in one hand, and some papers in the other.\u00a0 Clumsy and off-kilter.\u00a0 Managing to catch her far away towards another building, she graciously walked back quickly with me.\u00a0 After lots of back and forth, a more senior administrative person, the same person that the doc had called earlier, came in.\u00a0 We all came to agreement to let the hospital accelerate the process on their part to attempt getting it directly from Pfizer Korea; failing which we’ll just fall back to ordering through government and pay for it first to start.<\/p>\n The gates to the outpatient cancer department corridor shut after we exited.\u00a0 The second 2nd time now.\u00a0 I hope this does not become habit.\u00a0 7pm and we still had shots to get.\u00a0 Guessing the inpatient process, since the outpatient desk was now unmanned, we somehow got to the correct area and nurse.\u00a0 Having someone with us that spoke the language helped of course.<\/p>\n
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