Lights at the End of the Tunnel. Of Moon Shots and Medicine.

As I glanced through the obituaries the other day (yes, I have reached that stage in my life) I noticed a death notice with funeral arrangements for an oncologist I worked with twenty years ago. Of course I was saddened to hear of his passing, but what immediately came to mind was a conversation with a different oncologist that I overheard a long, long time ago–1976, to be precise.

It was the very beginning of my 2nd year at the University of Illinois School of Medicine. M1 Year had been spent buried in textbooks and anatomy lab, but with the onset of M2 Year, our class had (very limited) entre into the clinical world.

We were placed in groups of four, and each week every group had a pair of three-hour sessions in a clinician’s office. My group’s assigned physician was a busy oncologist who tolerated our being in his office but didn’t let us do much with his patients, and didn’t offer much insight either. But at least we got the vibe of being in the same general vicinity as living, breathing, patients.

At the end of one Tuesday session, our oncologist told us not to show up for that week’s Thursday session, as the office would be closed while he attended a funeral.

“Do you go to all your patient’s funerals?” the boldest of our foursome of M2s asked.

“I don’t go to ANY of them,” was the rather brusque reply.

A couple of that oncologist’s attitudes were transmitted to us in that brief exchange. “First,” he was conveying to us, “as a physician, you must keep your distance from your patients. Medicine is your occupation, maybe even your passion, but the patients are not your friends.”

“Second,” he seemed to be saying “I am an oncologist. All my patients die.”

As I said, that was a long, long time ago. I followed my talents to a medical field where I have so little patient contact that there is little risk of patients becoming my friends. Instead many of my friends have become my “patients”, the downside of being a 60-something prostate pathologist with a cadre of friends my own age.

But more importantly, oncologists no longer need to feel that their patients will die from their disease. Tumor screening (colonoscopy, mammography), leading to early cancer diagnosis, the use of genetic evaluation of tumors to guide therapy, the fantastic advances in understanding tumor immunology-these are wondrous tools that have made many cancers curable or converted them to chronic, treatable, conditions rather than rapidly lethal nightmares.

We aren’t at cancer nirvana yet. Treatments are still too expensive, life-style factors still put patients at risk. Some malignancies still baffle the best experts.

But perhaps in my lifetime, the Cancer Moonshot will succeed. And when an oncologist says “I don’t go to cancer patient’s funerals” it will be because there are none.

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We Save Lives (and I Apologize)

Words have an impact. Whether the speaker is a politician, an entertainer, or a blogger, they must think about the words they choose–and choose carefully. I try to do that, but despite my scrupulous care, I made a blunder in my word choices in a previous blog and I want to apologize for it.

You may recall my last posting conveyed some thoughts on my profession, ranging from Sherlock Holmes to surgeon’s “fingerprints. And in a section dealing with statistics, I said “Some days every prostate I look at will be malignant and I feel like Dr. Death.”

I really should have known better. Within a few hours of posting, I received the following from Marty, a friend, and prostate cancer warrior:

What?

No, no. Better to realize you are giving these men (myself included!) a 2nd chance at life as they and their doctors learn that they now need to enter the “treatment phase” of their now discovered prostate cancer.
And B’ruch HaShem may that treatment extend their lives for many productive years to come!

We MUST stay positive.

Marty was so right. The diagnosis of prostate cancer is absolutely not a death sentence. By far, most men diagnosed with prostatic cancer will live long and fruitful lives, enjoying careers, family, and free time.

So instead of referring to myself as Dr. Death, I should have chosen an honorific like Dr. Decision Tree (I know, I know, it doesn’t have much zing.) My diagnosis is a key piece of the data set that guides the patient and his medical team as to whether to treat (surgery, radiation, hormonal modulation, immunotherapy) or not to treat (active surveillance) the patient’s cancer.

(And while we are talking about prostate cancer, here is my annual plug for PSA testing. Ask your physician if it is right for you and the men in your life.)

Marty, you have improved my mindset. I will watch my words with the focus of a laser beam. You reminded me that, as one of my previous partners used to say, “We are pathologists. We save lives!”

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Am I A Prostate Guru? Someone Thinks I Am!

As a 12-year-old camper in the summer of 1968, I was my cabin’s nominee for the title of Guru of Camp Chi, 3rd Session. I ran a strong campaign, with a catchy jingle based on “Strawberry Fields Forever.” Sadly I lost in a heated battle with a candidate from another cabin. As was customary way back then, I graciously conceded the election to my opponent, without asking for a vote recount. However, I never returned to Camp Chi.

I haven’t thought about being a Guru in the 53 years since then. People who weren’t alive in the 1960s may ask “What is a guru?” Webster’s has several definitions for the word, including “a personal religious teacher and spiritual guide in Hinduism,” and “a person with knowledge or expertise.” Definitely an honorable thing to be. So I was quite surprised (and quite pleased) to have that appellation given to me the other morning.

Dr. M, one of our more senior urologists had stopped by to introduce his young new associate to the corporate and laboratory team at our facility. I gave the two physicians my standard lab tour, one that I have been giving to new employees of our group for years–a little lab history, a bit of explanation of our lab processes, and some back-patting of our staff. Fifteen minutes of time, and a chance to put a nice shine on the lab’s place in the corporate hierarchy.

As the tour moved from histology to chemistry, from cytology/FISH to our new molecular studies lab, Dr. M became more and more effusive about how excellent the lab was, and how we were the glue that held the group together. I was certainly smiling behind my mask.

And then came Dr. M’s final pronouncement. “Les is the Guru of Chicago prostate pathologists.”

OK, Chicago prostate pathologists are not the biggest set of which to be Guru. The network of Chicago area pathologists who do mostly urologic pathology isn’t enormous. But between all the university medical centers, the giant private hospital systems, and a few big commercial labs in the area, there are a lot of great pathologists and lots of prostate biopsies being analyzed. But yes, I probably see more prostate biopsies than anyone else in the metro areas — 18,000 prostate cases seen under my microscope over the last 15 years would be my best guess.

But I think Dr. M’s comment about “Guruness” was meant as more than just a comment on the number of cases I have seen through the years. I hope he was summing up that along with my associates, I have helped our large urology group provide sterling health care to our patients throughout Chicagoland. That is certainly our goal, and it’s good to know the lab is appreciated.

And after more than 50 years, I am proud to say I am finally a Guru. But I still don’t think I am ever going back to Camp Chi!

The opinions above are those of the author and not necessarily UroPartners LLC.

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Every Paper Clip Is Another Life Changed

A small cylindrical plastic container sits on the desk behind me. I am not sure what it originally contained but now it is filled with paper clips. A quick glance tells me it must have a couple of hundred clips inside it, and every day I add a few more. I empty the receptacle a few times a year, but in the meantime, each clip tells me that someone’s life has been changed.

How is that so?

Medicine is more and more digital these days. You complain to your friends about how your internist spends more time typing into their laptop than they do talking to you. Your prescriptions go out to the pharmacy electronically, and reminders about your next appointment zip to your cellphone, instead of coming on a little postcard in the mail.

Here in the lab, we are digital too…but we still use a lot of paper. While most of the blood tests we do are managed without anything written down (each analyzer “talks” directly to the interface that sends results to our docs), we handle our biopsies quite differently.

Our Laboratory Information System (fancy name for lab computer) contains all the necessary information about patient age, and gender, and the site from which a bladder or prostate biopsy has been taken. But when I am looking at cases from 15 or 20 different patients, it really helps to have this data printed out. Also, I like to create paper worksheets for my prostate cases on which I can mark my findings for each of the dozen or so cores from each patient.

When my final diagnosis for the case is benign prostate, I can enter my findings from the worksheet directly into the LIS myself with a few keystrokes, and then add my electronic signature. No extra trees need to be cut for those cases.

But for patients in whom I find cancer, I turn my completed worksheet over to our administrative team. They keyboard the complex findings into the LIS and then print a copy of exactly how my report will appear to the clinicians.

When those printed cancer case reports come back to me, I review the information, correct the rare typos, have one of my colleagues concur on the malignant diagnosis, and affix my electronic signature in the LIS. The report can fly off to one of our urologists through an electronic labyrinth.

But because I need to select the appropriate charge to the patient for the laboratory and pathologist services, the reports are paper clipped to a billing slip. When I separate the report from the billing slip I toss the paper clip into the little container behind me. The container fills, each added clip representing another person given the diagnosis they were dreading and hoping to avoid.

Making those diagnoses is a pretty awesome burden and at times a humbling experience. I just hope that I can be as consistent as a bucket-full of paper clips; doing my job, holding it together, and remembering that there are people whose lives may be altered by every one of those diagnoses. They all deserve the best that I can be.

The above is the opinion of the author and not UroPartners LLC.

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Has There Been a Pathologist in YOUR Life?

There are about 21,000 pathologists in the USA. That’s not a lot. And we are a pretty quiet bunch, even though some of us blog, a few of us tweet, and a handful probably Tik Tok and Instagram. Quincy M.E. may have been our show but that ended close to 40 years ago, Jack Klugman himself met his maker early in the last decade.

Yet pathologists matter! We make the diagnoses on the biopsies that influence your treatment. We ensure quality in the numbers that tell how well your diabetes medication is working. We make sure your Covid-19 test is as accurate as current science can provide. We study the genetics of your tumor to predict its aggressiveness or the likelihood of passing it to your children. And we can be the final arbiter of how and why a loved one died.

Whether by nature or whether by circumstances, we are mostly behind the scenes. Unlike your heart surgeon, your internist, or even your urologist, you rarely get to choose your own pathologist. And even less often do you rave about us to your neighbors. “You need a CBC? Your really should get it done at Midtown Clinic–that Dr. Greene is a great pathologist.”

But are there some of you who have known of a pathologist and of the role they played in your healthcare? Maybe it was at a tumor board you attended. Maybe you went out of your way to review your slides with the doctor who read them. Maybe you called with a question about your Prostate Specific Antigen (PSA) blood test.

If any of the above pertains to you, I’d like to know about it. Leave a comment, or drop me a line at les.raff@post.com. Let me know about any pathologists who stood out, who gave you knowledge, who made you feel cared for.

Please share, retweet, or forward this post, especially to those you know who have had an interaction with the healthcare system. I’d like to collect your stories for a future blog, or maybe more.

In the meantime, be well!

The opinions expressed above are those of the author and not UroPartners, LLC.

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Hail The Lizard Brain–Pathology’s Friend

I once had an experienced colleague named Paulo who claimed that within a second of starting to examine a Pap smear on his microscope he could tell whether it was going to be abnormal or not. Paulo “could smell it.” Since most pathologists I know have long had their olfactory sense dulled by the constant fetor of formalin and xylene, it was clear he was not literally smelling the glass slide on the microscope stage. Rather, his subconscious mind had taken notice of some subtlety, some minute, undefinable but not insignificant clues, that had his frontal cortex on alert. Soon he would find the cells that would lead to his assigning a grade of atypia to the slide and necessitating follow-up for the patient from which it had come.

I think of Paulo’s words often as I scan through hundreds of prostate biopsy cores each workday. There are definitive characteristics that define cancer of the prostate. Look up the description in a general pathology textbook and you will read about things like large nucleoli and invasive growth pattern. Turn to a text geared more for someone who specializes in urologic pathology and little tips like blue-tinged mucin and red crystalloids are pointed out as useful aids in the diagnosis. But frequently, long before I see those signs, I know I am dealing with a malignant prostate biopsy.

Just like Paulo with his Pap smears, thousands of hours of training and experience have made me aware of undefinable, indescribable, attributes in the patterns I see below me on a microscope slide. Maybe it relates to the density of glands on the slide. Maybe it is the way a certain cluster of those glands traverses the narrow width of the biopsy core. Whatever the signs are they trigger my “lizard brain,” deep in the primitive parts of my grey matter. It puts me on high alert–the odor of cancer is around the corner.

I am sure this feeling is widespread among pathologists. Whether dealing with a colon biopsy, a breast biopsy, or a thyroid gland aspiration, the well-trained, finely tuned pathologist has a sixth sense. Sure, we need to find the definitive microscopic signs, the nucleoli, the abnormal mitoses, the intranuclear inclusions– but sometimes we know before we see them that they will show up.

I suppose the radiologist feels the same way when he first looks at a chest x-ray and the surgeon does too when she first puts her hands on a tender belly. He knows there is a lung tumor, she knows the appendix is ready to burst. It may take a moment before their frontal cortex can describe how they know what they know–but as Paolo used to say, they can smell it.

Jim Morrison was the Lizard King. I will settle for just listening to my internal lizard. Especially when it roars.

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Is This a Scare Technique, or Good Pharma Advertising?

OLYMPUS DIGITAL CAMERA — Uncoagulated blood.

How do you sell an anti-coagulant drug in a pandemic? If you are giant pharma such as Pfizer and Bristol Myers Squibb, you run a pair of radio and TV commercials putting a scare into listeners and viewers. Ads that tell you that if you have symptoms of shortness of breath, leg pain, or palpitations you need to run, not walk, to connect to your healthcare professional because as the tag line says there is “no time to wait.”

I’m not sure why these commercials, featuring a real cardiologist and a real ER doc bother me so much. I am a physician. I believe in early diagnosis. I even believe in disease screening, as those of you who are familiar with my involvement in PSA screening and prostate cancer know. But these scare tactics drive me up the wall, especially when the ads run back-to-back as they sometimes do.

The probable cause of my discomfort is that these ads, masquerading as a public service, are clever ways of pushing for use of Eliquis, an effective anticoagulant used in the treatment of pulmonary emboli, deep vein thrombosis, and atrial fibrillation. The drug isn’t mentioned in the two ads, and perhaps that’s what bugs me so much. I don’t love, but I have gotten used to, ads that tell us how wonderful our life with migraines, psoriasis, and rheumatoid arthritis can be with the proper (expensive) prescription medications. At least those are clear-cut advertisements. Nothing sneaky. It’s the non-mention of Eliquis in the two new ads that sets my teeth on edge.

Maybe I am being a pre-holiday, middle-COVID, Grinch. Maybe these spots are getting the right people to see their clinicians and they aren’t petrifying a lot of other viewers who are just having gas pains. And if in so doing, the ads sell some Eliquis, so be it.

What do you think? Let me know.

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Knives, A Puff Of Smoke, and Me. What Could Go Wrong?

John Belushi would have made an excellent neuropathologist!

(Rated SG for Slightly Gross)

Do you remember Friday afternoons when you were a kid in school? The teacher’s voice would drone on and on. The minute hand on the wall clock would move slower and slower. Time would freeze.

You kept staring out the window, at the shining sun, at the park at the end of the block. You couldn’t wait to get outside and play some ball. Or snow was on the other side of the glass — and you were looking forward to an evening with friends at Alpine Mountain to practice some downhill ski runs. In any case, it sure was rough waiting those last few minutes.

No matter how bad you thought you had it on those long-past Friday afternoons, you most likely have nothing to compare to my Fridays in the early 1980s when I was a Resident in Pathology at a teaching hospital just outside Chicago. Because every Friday, at precisely 3:30, was brain-cutting time!

No, that’s not a clever nickname for some devilish oral Q and A the attendings would throw at us, nor was it a dastardly written exam. On Friday afternoons we would literally slice our way through the previous week’s autopsy brains.

I’ve written about autopsies before. But not the secret of brain-cutting. A brain removed at autopsy is a squishy mess. It’s the consistency of that disgusting lemon Jello mold that has been sitting under the hot sun since 11 am at your 4th of July picnic. Trying to examine it fresh is brain salad surgery.

So to prevent brain meltdown at autopsy, the fresh brain is carefully dissected from the cranial cavity (we won’t discuss how you open that up,) wrapped in gauze, and suspended on a network of strings in a large bucket of formalin for at least a week. Put THAT on your bucket list.

But eventually, we had to look at those brains. So every Friday afternoons Dr. D, our visiting samurai neuropathologist, would join the residents in the autopsy suite. One by one the brains from the previous week’s post-mortems, now solid enough to be cut, would be set before him. Though each had been soaking in running water for several hours in preparation for his attention, the formalin odor was still overpowering to the assembled residents. But the miasma didn’t seem to bother the Master.

Brandishing a long, glistening, and oh-so-sharp two-foot-long stainless steel knife he would approach each brain and go chop-chop-chop. He would then bow slightly and present us with thin slices of sashimied brain laid out in precise rows on a cafeteria tray. With the tip of his blade, he would point out the abnormalities–the tumors, the infarcts, the paleness of the substantia nigra in Parkinson’s Disease. He guided me through the pink blush of increased vessels in Moyamoya Disease, a rare vascular disease whose name — “puff of smoke” in Japanese — memorialized the appearance of increased blood vessels in an angiogram.

Dr. D had seen it all and explained it all.

Our residents may not have been happy to be in that autopsy suite late on a Friday afternoon. Maybe the good neuropathologist didn’t want to be there either. So many other places we all could have been. But no matter how much we hated it, we learned our neuropathology — at the point of a sword.

But it is a shame that I never did learn how to ski!

Use your very functional brain–VOTE!

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Quantum Microbiology–Things Get Interesting When They Get Small

Everything is getting smaller. Google has announced that it has created a quantum computer, the Holy Grail of techies. While the computer itself is a massive energy suck, the computational power is lodged in subatomic particles. I don’t understand the science, but I know those subatomic particles must be pretty, pretty, pretty small.

In the lab, we are shrinking things down too. Acting on the theory that nothing stays the same, here at UroPartners Laboratory we are embarking on a fantastic journey into the miniature world of DNA analysis. We will be adopting a technique known as polymerase chain reaction (PCR) to help us solve the riddle of chronic urinary tract infections.

Why are we doing this? Urinary tract infections (UTIs) cause irritating symptoms and can lead to very significant complications such as sepsis (bloodstream infection,) with lots of Emergency Room visits and hospitalizations. Serious, painful, and costly. We have traditionally made the diagnosis of UTI by bacterial culture; taking a urine sample, spreading it out on a Petri dish covered with agar, sticking the plate in an incubator, and checking the next morning to see if anything has grown. Then comes the process of identifying the growth (disease-causing bacteria? yeast? contamination?) and checking what antibiotics can stop the growth.

It can be a two to three-day process, and it is not perfect. Some bugs don’t want to grow on our little Petri dishes or they may take too long to show up. We do our best, but we know there are many patients who are left without an answer and suffer long-term disease or unsettling complications.

So we are turning to PCR. Our lab will soon be able to examine a urine specimen and in a few hours identify the DNA signatures of the various bugs present. We will also identify the genes that cause the bugs to be resistant to various antibiotics. Better information in a shorter time. A definite win-win.

Like all new technology, PCR for microbiology isn’t cheap. But studies have shown the overall cost to the healthcare system is lowered by eliminating all those ER visits and hospital admissions. And we don’t plan to use the test in all cases, just the problematic ones.

We have to do some construction to create a “clean space” where the DNA in each specimen can be kept isolated from other specimens, so it will be a few months before we get started. But it’s always exciting to start something new. And a hoot for this old dog to learn a few new tricks.

The opinions above are those of the author and not of UroPartners LLC.

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Did a Vegetarian Diet Cure a Prostate Cancer? I Need More Evidence.

prostate-cancer-low-and-high-grade — Microscopic appearance of less (left) and more (right) prostate cancer.

“I went on a vegetarian diet and my prostate cancer is gone!”

That was the Facebook post in a prostate cancer support group I occasionally follow. My immediate thought? Sorry, but I disagree with you. Based on the evidence you posted with that click-baity headline, I don’t think there has been a miracle cure. You posted pictures of a lab order with a diagnosis of prostate cancer. And you followed up with a picture of a pathology report (something I know a bit about) of a set of prostate biopsies from 15 months later indicating no malignancy was found. I am happy for you, I really am, but it doesn’t mean your eating habits have cured you, or that going on a vegan diet will cure other people.

A bit of background on prostate cancer. Back in the “good old days” prostate cancer was diagnosed by your internist with a good old rectal exam, or when you were being evaluated for symptoms such as an abnormal bone fracture. Most likely those were aggressive cancers, with growth often stimulated by the male hormone testosterone. Treatment consisted of surgery, or radiation, or using medicine to block the testosterone effect, or surgical removal of the source of that hormone — yes, you know what that means.

Since the advent of the PSA (prostate-specific antigen) blood test era in the 1990s (I am a believer) more prostate confined, less aggressive tumors are being identified. And based on the patient’s age, medical status, and some “under the microscope” considerations, many men with these tumors are being offered active surveillance – no current treatment, but regular PSA check-ups and repeat biopsies every year or two. If repeat biopsies show a more angry looking tumor, treatment can be considered.

And if the repeat biopsies are negative? Does that mean cure? Nope. Prostate biopsies sample only a small fraction of the prostate gland. And repeat biopsies are never in exactly the same location as the previous biopsies. So a small tumor that was sampled on the first go-round might not be in the path of the biopsy needle 15 months later. It doesn’t mean the tumor has gone away, though the tumor most likely hasn’t significantly grown. Of course, that is great news for any patient, but it isn’t the same as a cure. Surveillance is still necessary.

Is your vegan diet good for you? Sure, there are health benefits. And perhaps removing meat from your diet has removed some factors that might stimulate tumor growth. So I would never tell you to give it up. But I believe that a vegan diet cures cancer as much as I believe another post I read on Facebook that day–the one that says a sixteen year old has invented a perfect test for cancer diagnosis. But that’s a story for another day!

The above is the opinion of the author and not UroPartners LLC.

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