[Photo gallery: Follow along on Bart's hospital journey.]
Such rare conditions promise to complicate comparative-effectiveness policymaking, experts maintain, because they don't occur often enough to be rigorously studied to determine which, if any, treatments work. Even when the circumstances are not so rare, medicine's various possible responses may have pros and cons that offset one another, says Gregg Zoarski, an interventional radiologist at UMMC who faces such a conundrum when advising patients with small brain aneurysms. The coil procedure he performs to cut off an aneurysm's blood supply causes it to burst in a small percentage of cases, sometimes leading to a stroke or even death. Doing nothing, though, carries a 2 to 3 percent yearly risk of the aneurysm bursting on its own. He can't just turn to studies to tell him how to proceed, he says, because researchers themselves aren't in agreement.
When research can point to a treatment's clear benefits, certain trade-offs may nonetheless be unacceptable to patients. Whenever surgeons delve into the brain, for example, they chance altering the person's unique talents. Where is creativity located within those intricate folds of tissue? Or tone recognition, or pitch? Those are the questions Jennifer Friend, 28, a music therapist with epilepsy, posed after her UMMC neurologist told her that removing brain tissue in her temporal lobe could halt her twice-monthly seizures. A wealth of data shows that the procedure completely alleviates seizures in about two thirds of patients, improving the overall quality and even the length of their lives.
But while neurological testing can adeptly pinpoint regions in the temporal lobe vital for hearing, language, and memory, not so with musical abilities, says neurologist Jennifer Hopp. And a handful of studies suggest that temporal lobe resection surgery may lead to a decline in abilities to perceive meter and tempo and to recognize emotions evoked in music. Though Friend would finally be able to get her driver's license if she had the surgery, she declined. She says the passion she feels about her job—composing guitar tunes to help psychiatric patients express their moods—means more.
Part of the challenge (and thrill) of practicing medicine comes from handling the unexpected under pressure. While Hanna had promised to try to save Simmons's kidney, he realized upon peering into the open abdominal cavity that one of the masses was much larger and more extensive than it had appeared on the CT scan less than four weeks earlier, which often happens with fast-growing tumors. What's worse, it had completely wrapped itself around the ureter, the duct that connects the kidney to the bladder. Hanna called two urologists and urologic surgeon Michael Phelan into the OR for an on-the-spot consultation. The two surgeons took a break to go tell Rhonda there was a 90 percent chance the kidney would be lost.
Back in surgery, based on evidence that the tumor had spread beyond the lymph nodes into the surrounding abdominal lining, Hanna decided to order a relatively new on-the-table procedure in which a high dose of heated chemotherapy drugs is poured directly into the abdominal cavity. Although Hanna had never used the method for testicular cancer, he'd used it with some success against similar tumors in the appendix, colon, ovary, and stomach that had spread to the abdominal lining.
To map out the regimen for newly diagnosed cancer patients, the oncology team in each specialty at UMMC meets once a week to pore over medical histories, imaging scans, and biopsy slides and weigh the risks and benefits of various treatments. At a May breast cancer meeting, 17 experts, including surgeons, nurses, pathologists, and medical oncologists, gathered to discuss whether it was wise to initiate chemotherapy to shrink a large breast tumor in a woman who had missed so many appointments in the past that her tumor was now inoperable, or whether they could give the woman some pills she could take at home. Reviewing another patient, they pondered: Was it smarter to first treat her aggressive cervical cancer with radiation or to remove her small breast tumor? "I think at this point her cervical cancer trumps her breast cancer," argued Anil Dhople, a radiation oncologist. "She has a low-grade breast cancer and a bleeding cervical cancer. I think the cervical cancer needs to be addressed first." The breast surgeons responded that an immediate mastectomy would delay the cervical cancer treatments only by a couple of weeks at most. The matter was settled by Katherine Rak Tkaczuk, director of the breast evaluation and treatment program. "We can give her hormonal therapy pills to potentially shrink her breast tumor during the seven weeks she's getting her radiation therapy and chemotherapy for the cervical cancer," she advised.