Deficiencies In End-Of-Life Care Extend Across Ethnicities


By Barbara Feder Ostrov

What kind of care do you want at the end of your life?

elderlyStanford University researchers put that question to members of three major ethnic groups in the San Francisco Bay area and found little variation in their responses.

“There is a common humanity – people want to live as long as they have good quality of life. When it is their time, they want to be consulted so they die in a way that they are respected, and they don’t want their families burdened,” said the study’s lead author, Dr. V.J. Periyakoil, director of the Stanford Palliative Care Education and Training Program and associate director of palliative care services at the VA Palo Alto Health Care Center.

Regardless of ethnicity, however, the researchers found that access to high-quality end-of-life care is often hampered by lack of financial means, poor communication with health providers, cultural mores and family conflicts. The study, involving more than 300 white, Asian and African-American seniors, was published Nov. 18 in the Journal of Palliative Medicine.

Periyakoil, whose earlier research focused on how doctors discuss end-of-life care with patients from different cultures, said physicians often believe that talking about end-of-life care with patients of certain ethnic groups is taboo and that patients and their families are reluctant to have these sensitive conversations. The new study, though small and limited in geographic scope, suggests otherwise. The participants may have been more affluent and better-educated than their counterparts nationwide, given the region’s demographics, Periyakoil noted.indian elder

The researchers interviewed 315 people over 50 at senior centers in Fremont, Palo Alto, San Francisco, San Jose and Walnut Creek. The group included 38 African-Americans, 160 Asian-Americans and 117 Caucasians. Interviews, conducted in English, Burmese, Hindi, Mandarin, Tagalog and Vietnamese, examined participants’ attitudes toward end-of-life care and whether they had experienced barriers to getting quality end-of-life care for relatives or others in their community.

Researchers are still collecting data on Latino participants and plan to publish a separate study on their views, Periyakoil said.

While all of the participants in the study said they valued high-quality end-of-life care, about 60 percent said they had experienced barriers to getting it, most notably financial difficulties and a lack of adequate health insurance. Medicare typically covers only short-term nursing home care and offers hospice benefits to patients whose doctors certify they have six months or less to live and who are willing forgo treatment intended to cure their terminal illness.

white eldersThere were no statistically significant differences among ethnic groups in reporting barriers to care. But participants with less education were more likely to report that their biggest barrier to care was financial. Patients with more education were more likely to cite doctor behaviors that hampered end-of-life communication. And women were more likely than men to cite barriers to care overall, perhaps because they were more likely to be direct caregivers and have more experience with end-of-life needs.

Regardless of ethnicity, patients felt that “doctors were just too busy to initiate [end-of-life] conversations, reluctant to listen to their concerns and questions about EOL decision making, and often gave vague responses, making it difficult for the patient to comprehend their choices and make informed decisions,” the researchers wrote.

An estimated 2.6 million Americans die every year, but how the American health care system handles their last days is problematic across ethnic groups, according to “Dying in America,” a landmark report released in 2014 by the Institute of Medicine. Too many people end up having aggressive treatment that is ineffective and expensive and doesn’t contribute to the patient’s quality of life, the report found. Other research examiningracial gaps in attitudes toward hospice care and other studies has found differences among ethnic and religious groups in how they approach end-of-life decisions.

But people want to talk about it regardless of background, says Dr. Steven Pantilat, a University of California, San Francisco professor of medicine and director of UCSF’s palliative care program, who was not involved in the study.

“What this study tells us is that all of our patients want us to have these conversations,” Pantilat said. “They’re waiting for their doctors to bring it up, to not be rushed, to communicate sensitively.”Asian Senior

A new federal policy may make those conversations easier – and more routine. Starting in January, Medicare will reimburse physicians for discussing end-of-life care. That policy infamously – and incorrectly – was derided as promoting “death panels” during the debate over the Affordable Care Act and a version of it was dropped from the legislation. The counseling will cover what kind of medical care patients want to receive as they approach their last days.

Periyakoil urges patients of all backgrounds to prepare for these conversations, and new planning tools are available in different languages to help. Among them is the Stanford Letter Project, which helps patients write a letter to their doctors about the end-of-life care they do and don’t want in languages including English, Spanish, Mandarin, Vietnamese, Hindi, Urdu, Tagalog and Russian.

In one redacted letter provided by Periyakoil, a woman named Patricia writes: “I do not want my longevity to be more important than my comfort.”

Pantilat advises the doctors he trains that they don’t need deep knowledge of the beliefs of every religion and culture they might encounter, because every patient, of whatever ethnicity, has different goals.

“If we come in with true curiosity, respect and openness, we can learn a lot about how to take care of someone in a sensitive way,” he said. We need to ask: “What do I need to know about your culture and your family to take good care of you?”

Complete Article HERE!


Some Older Patients Are Treated Not Wisely, but Too Much

By Paula Span

older patientsOver many years, the 77-year-old patient has managed to control hisType 2 diabetes. Thanks in part to daily doses of a drug that reduces blood sugar, his glucose level is a very low 6.5 percent.

Like a lot of older people, he copes with multiple medical conditions, including high blood pressure and severe kidney disease. But with four prescription drugs, plus Tylenol forlower back pain, he’s doing reasonably well.

Oh, and he’s a hypothetical example, concocted by researchers at the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System. They sent this fictional case study to primary-care professionals at Veterans Affairs medical centers across the country and asked a series of questions about the man’s treatment.

The researchers believed their nearly 600 respondents — mostly physicians, but also nurse practitioners and physician assistants — would recognize that such a patient risked developing dangerously low blood sugar, called hypoglycemia. But no. About half these professionals said they wouldn’t worry about potential harm from the man’s rigorous treatment regimen.

Evidence is accumulating that older adults with diabetes, hypertension and other conditions should be treated less aggressively than they commonly are. “Deintensification,” the Michigan researchers have named this approach.

As this and another related recent study have shown, not for the first time, getting that message out to practicing physicians has proved difficult.

“In our health care system, we are all more scared of failing to do something than of doing too much,” said Dr. Jeremy Sussman, a primary care physician and research scientist at the Ann Arbor hospital.

Under current guidelines, most older patients with diabetes don’t have to get their blood sugar to rock bottom; a 7.5 or 8 percent blood glucose level (measured as HbA1c, an average of several recent readings) produces the same benefits as very low glucose. Blood pressure readings, too, should be allowed to rise as patients age — up to 150 millimeters of mercury for systolic pressure. The previous goal was to keep it below 140.

There are good reasons to be less vigilant. In older people with diabetes, for instance, maintaining very low blood sugar — often called “tight control” — can do more harm than good. “People can feel fatigued and weak, get cold sweats, feel like they’re going to pass out,” said Dr. Tanner Caverly, lead author of the Michigan survey, published in JAMA Internal Medicine. Thefainting and falls that may result can have devastating consequences.

Further, a widely cited study called Accord, published in 2008 in The New England Journal of Medicine, found that intensive therapy to reduce blood glucose actually resulted in higher mortality.

Yet a large national study by Dr. Sussman and his colleagues, published last month in JAMA Internal Medicine, reveals how rarely deintensification occurs among patients over age 70.

Reviewing Veterans Affairs data on more than 211,000 patients, the researchers found that fewer than 19 percent of those with very low blood pressure had scaled back their medications. Only 27 percent of those with very low blood sugar had done so.

“There’s been a huge effort to ensure that fewer people are undertreated,” Dr. Sussman said. “Now, maybe we’ve crossed the line and too many people are overtreated.”

Examples of both extremes are easy to find.

Among older adults, substantial proportions still don’t take advantage of vaccines, among the simplest of health protections. A third of those over age 65 didn’t get flu shots last season, according to data from the Centers for Disease Control and Prevention. More than 40 percent haven’t been vaccinated against pneumonia, and fewer than a quarter have gotten the shingles vaccine.

But older Americans receive too many colonoscopies and too many mammograms. Last year, a study found that more than half of nursing home residents with advanced dementia, a terminal disease, were receiving drugs of questionable value; about a fifth took statins to lower cholesterol.

Overtreatment, however, rarely brings the sort of hand-wringing that undertreatment does. You might think it would be welcome news that older diabetics can do well with lower doses of medication, and that in some cases they might be able to stop taking glucose-lowering drugs altogether.

Tight control takes great effort, and it makes sense for young and middle-aged people with diabetes. The benefits accrue slowly, over years, so younger patients are more apt to receive them. The young have stronger bones and better balance, so they are less likely to be injured in the falls that too-low blood sugar can cause.

Older, frailer people with lower life expectancy and many additional health problems face different trade-offs.

“As you get older, the benefits go down and the risks go up,” said Dr. Sei Lee, a geriatrician at the University of California, San Francisco, who has written about the subject for years. “What was good for you at 55 might be bad for you at 75.”

As a member of the American Geriatrics Society’s Choosing Wisely panel, Dr. Lee helped draft its recommendation that a 7 to 7.5 percent blood glucose reading is a reasonable goal for healthy seniors. For those with additional health problems and life expectancies of less than 10 years, the panel suggested a 7.5 to 8 percent goal, rising to 8 to 9 percent for those with many medical conditions and few years ahead.

Given all that, it’s disappointing that more primary care providers in the new Veterans Affairs study never thought to tell our fictional 77-year-old that he could afford to let his blood glucose rise a bit, and maybe eat a cookie once in a while. But sometimes patients themselves resist, especially if they have been dutifully monitoring their disease for years.

Dr. Sussman recalled a veteran, about 80, who took pride in the way he’d managed his illness, testing his blood several times a day, injecting insulin, keeping his glucose below 7. He had lost weight with age, however, so Dr. Sussman suggested he stop insulin shots and begin taking the diabetes drug metformin, which comes in pill form.

The man gave it a try. “But he and his wife never lost their discomfort with doing less than they had been,” Dr. Sussman said. The patient went back to the injections.

At least his doctor had pointed out the option and explained the likely benefits. In the new Veterans Affairs study, nearly 30 percent of respondents said they lacked the time to discuss the risks and benefits. About a quarter said they feared that reducing the fictional patient’s medications could make them vulnerable to a lawsuit.

More than 40 percent worried that higher blood glucose would violate their institutions’ performance measures, the report cards doctors get — even though the Department of Veterans Affairs has never specified a target below 7 percent for these patients.

Just the contrary: The department last year announced a National Hypoglycemic Safety Initiative, changing its approach to diabetes management to avoid intensive treatment when it’s not warranted.

Still, older adults who haven’t reassessed their diabetes or blood pressure regimens for years probably should be asking their doctors if they can or should make changes. The doctors, for now, might not raise the subject themselves.

“It’s one thing to find out about something new and exciting and do it,” Dr. Sussman reflected. “It’s harder, emotionally, to look at something you’ve done for a long time and think, maybe this isn’t so good. And stop.”

Complete Article HERE!


All In This Together: Coping With Advanced Illness and Dying as a Family

By: Fred Nelson MSW, RSW

“The moment we heard about Dad’s cancer diagnosis, everything changed in our family. My sister has always been kind of withdrawn. Well, she started to take over. I felt like my own world had ground to a halt; I couldn’t do anything useful. My brother just got busier and busier – totally absorbed in anything as long as it had nothing to do with Dad. Our first family dinner together after we got the news: we were like strangers. We didn’t have a clue how to even talk to each other.”

We all have our own ways of responding to and getting through a difficult situation. Sometimes we can predict pretty well what we will feel and how we and others will react. Sometimes it’s a complete surprise – to ourselves and everyone around us. The fact is that we are all affected – subtly or in a big way – when someone in our family is diagnosed with a serious illness. Our outlook on life can change. Our behavior can change. Our roles can change. Naturally, all of this affects how we come together as a family.



‘Family’ is whatever it means to you: a parent and kids; a group of siblings and their partners; a multi-generational extended family; a group of friends who have stuck together through good and bad. That part doesn’t matter. What does matter is that every family, however structured or defined, has its own established roles, rules – generally unspoken – and ways of communicating.

Here are some examples of rules, roles and patterns of communication that may occur within a family:

  • Nobody in the family talks about negative feelings. If you’re sad or angry, keep it to yourself.
  • If you have an issue with someone in the family, don’t talk to them directly; speak to Mum and she’ll deal with it.
  • We catch up on what everyone’s doing on Fridays after work.
  • Uncle Bill always mows the lawn and cleans up after a barbecue.
  • Nobody mentions Peter’s first wife, even when their son is visiting.
  • Only Dad can initiate discussions about family vacations.
  • Nobody ever praises a piece of pottery that wasn’t made by Mum.
  • We all congratulate Chris on his game, even when his team loses.
  • If you need to talk to someone about a disappointment in your life, talk to your big brother.
  • Aunt Julie can’t keep a secret.
  • New Year’s dinner is always at Uncle Remy’s – no exceptions.
  • Amanda is always the one who pushes for us to get together to plan our holiday activities.

family2All of this can be thrown up in the air like a deck of cards when someone in the family gets a serious, life-limiting diagnosis. And what happens when the cards come down? The possibilities are endless as family members:

  • deal in their different ways with strong emotions
  • consider how the future might unfold
  • move, willingly or unwillingly, into roles that have been occupied by someone else
  • work within or challenge established ‘rules’ about gatherings and ways of communicating

Even if individual family members stick pretty much to the roles they have occupied in the past, it is very likely that the intensity of the situation will ‘crank up the volume’ on the ways they interact with one another and force old differences to the surface. For instance:

  • I have never been compensated for the fact that Dad took you into the business and not me.
  • Who said this was my job, anyway?
  • Don’t tell me how I should feel!


Eventually, and sometimes right away, a serious, life-limiting illness means caregiving. Directly or indirectly, someone in the family is likely to become responsible for caregiving. The responsibility may be shared, but often it isn’t. And caregiving can be exhausting – emotionally, physically and financially. The emotional rollercoaster can be extreme (sadness to relief to hurt to fulfilment to guilt to satisfaction to tenderness to anger and resentment to just not knowing how to help). Physical challenges can be immense. (Am I ever going to get a good night’s sleep? How do I get him into this wheelchair?) And while many family caregivers will tell you that the experience is not only doable but life-enriching, tensions are inevitable. For instance, if the needs of a seriously ill family member outstrip the ability of a family caregiver to provide appropriate care. Disagreements over the right course of action are common between the main family caregiver and the person who is ill as well as among family members. Add to this mix, intense feelings, new or entrenched patterns of coping, and new roles, and it may be unrealistic to expect smooth sailing.


First and foremost, the person who is ill should remain the central decision-maker for as long as he or she chooses or is able to be.  It is also important for the person who is ill to decide who will make decisions on his or her behalf if necessary. Even if a single member of the family becomes chiefly responsible for the care of the family member who is ill, it is likely that other family members, perhaps all of them, will need to be included in some important decisions. Financial decisions are a good example, and people avoid them for a variety of reasons. For instance, a person who is dying may not want to face financial issues because doing so would require a genuine acceptance of his or her condition. Or it might mean confronting some differences in the ways individuals in the family see things.

The best advice from people who have been in this situation is to be practical, honest and straightforward. For example:

  • I know that you want to be in control of your affairs and money as you have always been, but I am concerned about the ‘what-ifs’.
  • If you haven’t made these decisions and completed the paperwork, I worry about us not being able to do what is important for you when you are unable to do so.

Telling people what they should do – someone who is dying or another family member – may lead to resistance and is usually not as effective as speaking for ourselves.  (E.g.You need to do this now vs. I am concerned that…)

In many families, there is a tendency to try to protect one another by avoiding frank conversations. If we talk about it, we will take away all hope. Or If we talk about death, it will happen sooner. Or This is just too hard for him/her to talk about, when in fact it might be truer to say, “This is too hard for me to talk about.  While such reservations are common, they can actually leave all involved (the person who is ill and family members) feeling isolated and that their feelings and concerns are not heard or understood. It can take a lot of emotional energy not to say what needs to be said. In the end, expressing ourselves to one another and going through tough times together can free up energy for something more worthwhile and help us feel more connected to one another.


family4Family members are not always on the same page at the best of times. In times of stress, disagreements, conflicts and anger are much more common. Anger often comes from a place of frustration, being misunderstood, being afraid or not being heard or acknowledged. It is a natural reaction to the threat of loss or loss itself. Hurt, fear and feelings of guilt can contribute to anger. Anger often surfaces when we feel insecure or vulnerable.

When everyone is under stress due to a serious illness and an intense caregiving situation, try not to take anger personally. If you can, consider – with as much compassion as you can find within yourself – where the anger is coming from and what feelings or experiences it might be rooted in. Remember that all relationships have a history and that past grievances commonly surface during times of stress. Counselling support can help provide a fresh perspective and help family member talk to and better understand each other, although there certainly are times when differences are too entrenched and individuals are too wounded to resolve issues.

A wise person once said, ‘At any given moment, human beings are doing the best they can.’ The bottom line is knowing what each of us can and cannot take responsibility for, and finding a way to be okay with that.


The presence of conflict doesn’t mean there’s something wrong with you or your family, although it certainly can feel that way. When conflict is making you feel like you or your family are failing, think again of all of the changes that are in play – changes in feelings, roles, family ‘rules’, situations, finances – and the stresses that everyone involved is enduring. In fact, it would be surprising if there were no conflict.

Again, with as much compassion for yourself and others as you can muster, step back, take a breath and consider everything this particular conflict is rooted in. Consider all the places that you and your family members find support – community, professional, through the health care system, friends and family – and figure out how to access them. Consider what you can do and what is simply beyond your control. Make sure to treat yourself with kindness and respect.

After all, you and your family members are dealing with the countless changes and challenges that come with caregiving and loss. There are no perfect solutions. But like other human beings, you are doing the best you can. Looking back on this intense time, you may, like many other families, be surprised by your resourcefulness and resilience.

Complete Article HERE!


Learning to Die


My mother taught me many things, including, in the end, how to die.

Her death went well, I told the few friends who I knew would understand my meaning: She was not in pain, she was conscious until the day before she died, she was at home, my sister and I were with her. It was a peak experience, revelatory and meaningful — something I wouldn’t have traded for anything — except her life.

No one tells you how discreetly death can make its catch, or how languorously. It rolls in like a low wave: It’s moving, and it’s not; she’s there, afloat, and she’s not; it simultaneously sluices through her and tugs her in its tide for hours, until she’s silently dispelled by its force.

I understand, now, why death has so often been personified in art — it’s maddeningly anonymous. Sylvia Plath’s Death is two people: the one who never looks up, and the one who smiles and smokes. But her suitors are too sexy and menacing to represent the remote, impassive, mundane death I witnessed. Jacques Brel’s Death is a spinster, a princess and a witch — all impossible: the experience of death could never be so monumentally solitary with this crowd of enablers on the sidelines.

My mother hallucinated lightly in the week before she died, and her morphine visions assured me that her death — or at least what followed it — would be O.K. “I wish I were a tree,” she said one day, which seemed reasonable in light of both her love of forests and the nature of her illness, multiple myeloma, which was whittling her bones away. She wanted to be solid again. She wanted to stand up and be rooted. A few days later she said brightly, “My father’s waiting for me.” She was ready to go.

On the night she died, five or 10 minutes after she stopped breathing, I held her in my arms and she was still there. An hour later, she was not. But she hadn’t been taken. I’m certain she had left, and seeing her go gave me the courage to think that I could do this myself, without fear.

I practiced in a dream. I was running along the rooftops of Lower Manhattan when I hit a sheer drop of 20 or 30 stories, and began to fall. I knew I would die, so I gave myself a quick admonition. First: Relax. It’s a long way down, and you could have a hell of an experience before this ends if you don’t tense up and miss it. Second: Stay horizontal so you get a clean hit and don’t make a huge mess. Third: On the ground, before you die, explain that this was an accident, not a suicide. People who love you deserve to know.

I hit the ground and found myself running again — scrambling around trying to get back to a building where I’d left a newly purchased book I was desperate to retrieve. I’d died and gone to — a bookstore. Life went on.

A month after her death, my mother was still dying. When I went to her apartment to sort her mail and pack up her things, she was there — a little less each week, but still. She walked in and flopped down on the full length of the couch with one outstretched hand brushing the floor, a Kleenex in her sleeve, surveying the vast empire of magazines on her coffee table. She appeared in my dreams, allowing me to hug her for a preposterously long time, though we both knew she was dead. This is how I held on to her for a few years — when I played it right. One night in a dream, for example, I spoke to her at length by phone, but when I asked her where she was, she sounded irritable and hedged, and the dream dissolved. So I learned not to ask.

And now, four years have passed. A gap has widened between what happened before her death and what’s happened since, and she’s slipped into it. They’re all gone now: the ghost mother, reclining on the couch; the missing person, dissembling on the phone; and the absent presence lingering in the woods where her scattered ashes have settled into the underbrush, buried under seasons of snow and wildflowers. And yet it feels as if I just met this radical new mother who did the unthinkable — the renegade who journeyed deep into the wilds of a terminal illness, shape-shifted magically before my eyes, and took off. It was an artless, innocent betrayal, based on a misunderstanding: I had simply thought she would live forever.

Complete Article HERE!


Coping and the experience of LGBT aging


LGBT End-of-Life Conversations

10 brief videos on an array of timly topics











By: Simon Fraser University Gerontology Research Centre
Featuring Brian de Vries, PhD


Deeply religious Jimmy Carter embraces cutting edge science in cancer battle


Listening to the 90-year-old Jimmy Carter’s press conference last month concerning his battle with cancer, one might assume his pre-political career to have been in medicine, rather than nuclear physics for the U.S. Navy’s early nuclear submarine program. Not only did the former president explain his surgery in terms of the precise volume of liver tissue resected and the size of the four metastatic lesions in his brain shown on his MRI, but he also outlined the treatment plan.Former president Jimmy Carter

Importantly, in response to more than one question regarding whether, due to his religion beliefs, age, or other reasons, he ever considered something other than what his doctors — topic specialists in oncology, surgical oncology, and radiation oncology — were recommending, he replied with a resounding “no”. Despite talking frequently about his religious faith, despite teaching Bible classes to kids on Sundays in his hometown church, Carter will do what he can to prevent nature from running its malignant course. He will not sink into the gutter of alternative, faith-based medicine, but quite the contrary. He his put his fate in the hands of science. In his case, that means immunotherapy, which currently is showing promise for just a handful of cancerous conditions, but that includes the one he has, melanoma. It also radiation therapy, targeted very precisely to the four lesions in his brain.

What the treatment will mean for Carter’s prognosis is not something that can be answered with great precision, given the small amount of information that’s been released about his condition thus far. What is both public and improves his prospects is the fact that the four brain metastases are tiny, approximately 2 mm each, and the fact that it’s a cancer that responds to the immunotherapy drug that he’s getting. On the other hand is a concern that other metastases may yet turn up in other parts of his body. Either way, however, Jimmy Carter apparently plans to make his battle with cancer very public, and potentially this can do a lot for cancer awareness that ultimately can save many lives.

Carter’s diagnosis

In recent years, health-centered media have done a fairly good job at making people aware of malignant melanoma. For this reason, the public has a fairly accurate image of melanoma as a type of skin cancer, in fact the most deadly type. Many people are aware that a change in in a mole or the appearance of a new, dark mark on the skin is not something to ignore, but something to have examined by a dermatologist and biopsied. But what’s not well known is that approximately 2 percent of melanomas begin deep inside the body, not in the skin. These internal melanomas come from melanocytes, the same types of cells that cause cutaneous melanoma. But, unlike cutaneous melanoma on Sun-exposed areas, you cannot prevent internal melanomas by controlling your Sun exposure, nor can you see them in an early stage with your own eyes.

In President Carter’s case, the only reason why doctors found his melanoma, initially in the liver, is that he had an abdominal magnetic resonance imaging (MRI) scan as part of a comprehensive exam after developing a very bad cold. After approximately 10 percent of his liver was resected biopsied, it was confirmed that the liver lesion was cancer, and specifically it was melanoma. However, the testing also showed that it had been removed with clear margins of healthy tissue around it, meaning that the rest of the organ was in good shape.

In a certain sense, the melanoma diagnosis after surgery was a relief for Carter, because initial presentation had looked as though it could have been pancreatic cancer, which runs in Carter’s family. His father, two sisters, and brother all died from it, and the liver is commonly a presentation site, even though it starts in the pancreas. But Carter’s doctors had a high level of suspicion that the melanoma had not started in the liver, that the liver lesion was a metastasis from another site. Consequently, they ordered more MRI scanning. This revealed the four spots in his brain and it’s the reason why some media outlets have referred to Carter’s condition rather inaccurately as “brain cancer”.

Different types of cancer affect the brain

What President Carter has is not “brain cancer”. It’s metastasis to the brain from somewhere else. Metastasis by cancers starting somewhere else actually is the most common kind of cancer to have in the brain. However, it’s important to distinguish brain metastasis from malignant tumors that arise in the brain itself. One category of primary brain malignancies is glioblastoma, which kills approximately 15,000 adults in the US each year and is the brain malignancy that Vice President Biden’s son, the late Beau Biden, may have had, based on reasonable speculation by the Washington Post.

It’s particularly important to raise awareness about brain malignancy and where state-of-the art medicine is at present, in light of a scientifically illiterate and extremely paranoid accusation made last June by writer Mike Adams of the pseudoscience publication Natural News. After outlining his opinion that the younger Biden was “killed by a combination of chemotherapy, radiation, and glyphosate”, Adams went on to slam the field of oncology with a string of accusations and insults:

Oncologists who prescribe chemotherapy drugs earn massive profits from those drugs, all while failing to disclose their own conflicts of interest to their patients. Unfortunately, chemotherapy kills far more people than it saves because its primary side effect is recurring cancer. Yes, chemotherapy causes cancer. And the ignorant oncologists who prescribe it actively encourage patients to avoid protecting their healthy cells with nutritional therapies such as medicinal mushrooms, anti-cancer foods and healthy oils such as cod liver oil. In fact, oncology as practiced today is a barbaric medical practice that quite literally kills people by the hundreds of thousands each year…Beau, it seems, was handed over to the conventional cancer industry which, sadly, told him he had a “clean bill of health” just 18 months before the cancer surged back… almost certainly worsened by the chemotherapy itself.

After attributing Beau Biden’s death to chemotherapy, Adams goes on to blame the herbicide glyphosate (an analog of the amino acid glycine) — and indirectly Hillary Clinton and others who support biotechnology companies — for Biden’s developing the malignancy in the first place. The possibility of a glyphosate-cancer connection has been addressed, and shown to be highly speculative, on the Genetic Literacy Project and other news outlets, but here we can address Adams’ alarmist assertions regarding conventional oncology treatments, and chemotherapy in particular.

Chemotherapy saves lives

There are two things that Adams got right, although he wrote about them so far out of context that they can do nothing but mislead the readers. First of all, people do receive chemotherapy and then die, and often this happens after they initially start to get better after following a cancer diagnosis; they go into what is called remission, but often the remission does not turn into a cure. That happens because many types of cancer respond well at first to certain cancer drugs, and then more resistant cancer cells take over.

What Adams didn’t say is that with many types of cancer, today the incidence of the cancer coming back after initial remission is reduced compared with a half century ago, because of increasing understanding of how the chemotherapy drugs work, increased capabilities of new chemotherapy drugs, and because of the development of systematic protocols for using particular chemotherapeutic “cocktails” of different agents. Adams also didn’t say that reason why patients die when cancer comes back after a remission is not that chemotherapy causes new cancer. He implied that in his article, but it’s completely false. What comes back is the same cancer that the patient had before.

The second thing that Adams got right is that many chemotherapy drugs can themselves cause cancer. As explained above, it’s not the same cancer that comes back within weeks or months in cases when chemotherapy doesn’t get rid of a cancer. Instead, the correct but out-of-context fact is that there are cancer drugs that can cause secondary malignancies decades later. This is particularly true of a category of anti-cancer drugs called alkylating agents. This is a huge issue in oncology, particularly in cases of people who are treated with those drugs for childhood cancers, who are then at elevated risk for other cancers decades later.

But what Adams did not say–what makes it extremely out of context–is the reason why we know about secondary malignancies caused by certain chemotherapy agents. We know about it because there is an increasing number of survivors of childhood, teenage, and young adult cancers who are walking around today and sometimes developing cancer 20, 30, or 40 years after chemotherapy, radiation, and surgery cured them of the cancer they had in their youth, that otherwise would have killed them.

In the 1940s and 50s, cancers, such as acute lymphoblastic leukemia (ALL) in children and Hodgkin lymphoma in teenagers and young adults, were nearly complete death sentences. But today, most of the kids diagnosed with these two conditions survive, and they survive because of chemotherapy. How did this happen? By the 1960s, oncologists had just a handful of chemotherapeutic agents. Sometimes, they worked a little for certain cancers. People got better, or went into remission for a little while, and a small fraction were actually cured. Overall, the cure rate was dismal, but then researchers started noticing that the cure rates varied a great deal from medical center to medical center. Different oncology teams were using and dosing the different drugs in slightly different ways. Some were combining more than one drug but the combinations also varied between institution.

Thus, in the 1960s and 70s, oncologists and scientists started having cancer teams report what their cases and treatments very systematically, and they started looking at the outcomes of different drugs, alone and in combination with other drugs, for different types of cancers.

What grew out of this approach was a knowledge base founded on the collective experience of oncologists around the world. This led to very particular protocols for combined chemotherapy cocktails for specific types of cancer. As the various cocktails were being developed, various new drugs were also introduced to mitigate the side effects, thereby allowing for more aggressive doses. Depending on the type of cancer, and the locations within the body, the chemotherapy protocols are also combined with radiation therapy and surgery, along with other types of drugs.

All of this together has given oncologists the ability to kill off cancer to the point that it does not come back, because any cell that happens to be resistant to one agent is killed by another agent, or by the radiation, or, if the tumor mass gets low enough, by the patient’ own immune system. Thus, while chemotherapy armaments today do include many old drugs used unsuccessfully 70 years ago, they way they are used today is very different, and for a bunch of cancers the rate of survival has increased significantly. At the same time, radiation oncology has also gone through major advances. Not only is the power of radiation that can be delivered to a tumor gone up steadily, but the targeting has gotten better, due to precise imaging with technologies such as MRI and computed tomography (CT) and nuclear medicine techniques. Also, the shielding has improved, which makes a huge difference, allowing delivery of powerful radiation only where it is needed while sparing healthy tissues.

Importantly, one of the main factors affecting survival is matching the precise staging of the cancer (where and to what extent is has spread in the body) to the appropriate treatment. Today, the staging is more precise that it used to be, because of improved diagnostic capability, and that is improving survival as well.

President Carter’s Treatment Plan

Based on what information is available, President Carter is now receiving radiation to the four metastases in his brain. There is a very good chance that all four lesions will be eliminated from his brain with minimal side effects, because of the small size of the lesions, the precise targeting, the high tech shielding, and because of one other reason: special agents can be given that will make the brain metastases more sensitive to radiation. Carter is also getting treatment with pembrolizumab, which is being called abreakthrough drug. It works by boosting the immune system, and therefore is part of an emerging type of therapy known as immunotherapy. Currently, immunotherapy has limited use for cancer across the board, but melanoma is one type of cancer where immunotherapy is showing particular promise.

Complete Article HERE!


Burial, cremation, or full fathom five? I can see the allure of a watery grave


Eighty-five-year-old twins from Brooklyn are setting off on what they say will be their final voyage. Their plan to die at sea has an undeniable romance

Sunset over the sea

‘The sea is where we came from in the first place. There’s a definite romance to saying goodbye to the land, and setting sail for that last adventure.

The endlessness of the sea offers an eternal alternative. Perhaps if we just pushed off into it, we could escape death itself – as if its amniotic waters might be a return to a universal womb. After all, the sea is where we came from in the first place. There’s a definite romance to saying goodbye to the land, and setting sail for that last adventure.

Van and Carl Vollmer, 85-year-old twins from Brooklyn, certainly think so. The brothers are about to embark on the handsome 158ft, three-masted barquentine, the Peacemaker, on a round-the-world voyage in search of remote islands and sunken galleons, from the Panama Canal to the Great Barrier Reef, the Philippines, and on to the Mediterranean.

In order to get there, the pair – who currently live on a powerboat moored on City Island – have bill-posted Brooklyn’s hipster district of Williamsburg with an enticing proposition: “Brooklyn sea captain seeking crew!” They’re advertising for a 12-strong, able-bodied crew of men and women, including a mechanic, deckhand, cook, nutritionist and an aquaponic gardener to grow vegetables on top of fish tanks – a kind of hip 21st-century version of Ahab’s crew on the Pequod in Herman Melville’s Moby-Dick. They’ll even get suitably retro uniforms of old-fashioned sailor pants with 13 buttons and yellow-and-white striped shirts. I’m guessing they’ll all have beards already.

But instead of a demented captain suicidally spearing a great white whale, the Vollmer twins are instructing their shipmates that when the time comes, they’ll be glad to go over the side. “To swim with the fishes for eternity”, as Van Vollmer says. “We want to spend the rest of our lives on this boat”, Carl adds. “We want to get thrown overboard”. Melville, who lived and died by the New York waterfront, would approve of such wild ambition. Having ended his own life as an ageing customs inspector on the Manhattan wharves looking out longingly to sea, the great writer probably wished he had done the same. Indeed, it’s a scene reminiscent of his last, elegiac seafaring tale, Billy Budd, whose protagonist ends up consigned to the deep: “…roll me over fair! / I am sleepy, and the oozy weeds about me twist.”

But not everyone is happy about the Vollmers’ intentions. At least one crew member, Steven, chosen by the twins as their first mate, is equivocal about this duty. “Van kind of brings it up and he’s like, ‘I want to teach you everything I know so when you dump me into the sea you can take over.’ I’m hoping that’s just some kind of expression. It’s not something I really want to think about.”

Not going gently into the good night but raging against the dying of the light, as Dylan Thomas recommended, has a long maritime tradition. It is an ambition peculiarly suited to the sea – particularly in our fractured archipelago of the British Isles. In Charles Dickens’s David Copperfield, Mr Peggotty, the Yarmouth fisherman, says of his brother-in-law Mr Barkis as he lies dying: “People can’t die, along the coast … except when the tide’s pretty nigh out … He’s going out with the tide. It’s ebb at half-arter three, slack water half-an-hour. If he lives till it turns, he’ll hold his own till past the flood, and go out with the next tide.” Nowadays, anyone hoping to swim with the fishes in eternity without going to the bother of sailing into the blue yonder can opt for burial at sea off the Isle of Wight, in a designated zone.

Meanwhile, the modern Odysseus takes to the ocean liner. Wealthy wanderers of a certain age have sold up on land to live at sea in permanently rented suites. A somewhat ominous-sounding company called Utopia caters to those who intend to spend the rest of their lives on the briny, while US websites discuss the practicalities, pondering, “Is cruise ship retirement cheaper than assisted living?”.

Beatrice Muller thought so. After her husband died on the QE2 as it sailed out of Bombay in 1999, she announced her intention to live on the liner till the end of her days, paying £3,500 a month for the privilege. Unfortunately for Mrs Muller, she outlasted the ship; it went into retirement in 2008. And although the stalwart senior citizen continued to defy the land – “I’ll keep on staying at sea”, she said, aged 89, “I don’t want to go back to housekeeping” – sadly, she seems to have ended up in a retirement home in New Jersey.

As someone who swims in the sea every day, I’ve often considered it as my last resting place; that like Barkis, I might be taken out with the tide. After all, I wouldn’t be using up valuable land space, or contributing to climate change. It sounds almost idyllic. “Full fathom five my father lies”, as Ariel sings in The Tempest, “Of his bones are coral made”, transformed “into something rich and strange”. But then I think of how lonely it might be, nibbled away by crawling slimy things where “the very deep did rot”, as the fated Ancient Mariner saw it. And would I really want to be recycled by lobsters, to end up in the food chain? Perhaps it’s not such a reassuring thought after all.

Complete Article HERE!