Letter to 20/20

Many of you heard the 20/20 segment on high-dose chemotherapy recently.  The following is a copy of what I sent to them in response to the segment.  vh

To Barbara Walters, Dr. Tim Johnson, and the Production Staff of 20/20:

I am appalled at the lack of understanding exhibited in your segment on high-dose chemotherapy with stem cell or bone marrow rescue (which I'll refer to as HDC/SCR for the remainder of this email) that was broadcast last Friday.

This lack of understanding is exhibited in six respects:

1.  The results reported by Dr. Bezwoda were, plainly and simply, cheating and should be discarded.  Any physician who recommended that a patient undergo HDC/SCR SOLELY on the basis of Dr. Bezwoda's study was not acting responsibly towards that patient in the first instance.

2.  It is clear from the comments included in the broadcast that the intermediate nature of the results reported by the largest of the
studies (the one presented by Dr. William Peters of Karmanos Cancer Center) was not understood.  Dr. Peters himself has publicly stated that he would not have expected any difference in results at 30 months but that he would expect differences to be visible at 60 months (5 years).  As a consequence of Dr. Johnson's misunderstanding of the statistical validity of any of the studies (exclusive of the discredited Bezwoda's study), I now have cause to pause about his reportage on other issues.

3.  I find that your failure to report that the mortality rates for this procedure itself at the best centers now approaches 1 percent a significant omission. Taking the "I know women who've died from this procedure" argument of Ms. Visco fails to serve your listeners who have active disease and who are struggling with the decision of whether or not to have this procedure. This is not to say that HDC/SCR is appropriate for all women who are presently considering the procedure.  But, they do deserve the opportunity to make up their own minds based on a fair representation of the available information.

4.  The fact that an irresponsible organization was willing to perform a second procedure (apparently outside of clinical trials) for Kimberly Farrell when her initial procedure failed so soon suggests more than ever that the importance of clinical trials cannot be underemphasized. The tiny little tagline stated by Dr. Johnson at the end of the segment was inadequate to emphasize this point.

5.  Dr. Johnson's failure to address either the issue of contamination of the stem cells by active tumor cells or the issue of methods to determine which patients who actually can benefit from HDC/SCR also suggests a lack of understanding of the situation.

6.  Finally, nobody should be doing HDC/SCR for solid tumors outside of a trial.  Trials are available for anybody who's willing to participate (see http://www.clinicaltrials.gov or http://www.centerwatch.com).  By the same token, even though there have been remarkable results of HDC/SCR for other than neoplastic diseases, i.e., mostly for autoimmune diseases, nobody in those situations should be doing this outside of a trial either.

As a former breast cancer patient who had the HDC/SCR procedure in 1992 at one of the world-class centers, I had the prospect of median survival time of 14 months and an 80 percent mortality rate at 5 years when I was initially diagnosed with inflammatory breast cancer.  That I am still alive 9 years, 1 month, and 5 days later I attribute to the entire treatment regimen I received, including the HDC/SCR.

I hope that your production staff will take a further look at this issue by examining a number of the studies which report successes in the use of this procedure.  If you'd like pointers to the reports of these studies, I'd be glad to send a list to you so that your staff members can take a look for themselves.

Pointer

Some of you who have been following the recent news stories on high-dose chemotherapy with stem cell replacement for breast cancer may want to read a different approach to the issue of means and medians.  Such an essay is Stephen Jay Gould's The Median Isn't the Message.  If you're reading the paper version of this, you can find the essay at:

http://www.cancerguide.org/median_not_msg.html

If you're reading this online, just click on the line above.

In a double-blind clinical trial, soy phytoestrogens were found not to be effective in reducing hot flashes in breast cancer survivors. Comment:  That the study was carried out in the context of a double-blind clinical trial gives this study more credibility and reliability than most of the studies of botanicals.   Quella et al.,  J Clin Oncology, 18:5 (March 2000), 1068.

A history of trauma has been found to affect the adjustment of women to the events involved in breast cancer treatment and has implications for both screening and treatment of these women.  Comment:  Because this has a negative impact on a patient's adjustment, it is important to involve psycho-social support teams in the early treatment of these women.  The article also implies that such teams should also be involved earlier in the process than they normally are, at the time of mammograms.  Green et al., J Clin Oncology, 18:5 (March 2000),  1084.

A review of studies on drug interactions for patients in palliative care shows that drug interactions have significant consequences for pain management.  The medical team's failure to recognize the major interactions can lead to overdosing when the effectiveness of a pain medication is underestimated and to undertreatment when the pain medication's effectiveness is overestimated.  Comment:  This review confirms what a number of patients report about medications for pain management.  Bernard and Bruera, J Clin Oncology, 18:8 (April 2000), 1780-1799.

Patients who were older or who had a poorer prognosis were found to be less likely to be referred for clinical trials than younger patients or those with a better prognosis.  Additionally, patients who delayed treatment decisions for a short time were more likely to participate in a clinical trial than those who made treatment decisions quickly.  The attitudes of physicians towards clinical trials and their associated treatment were found to be critical towards participation in clinical trials.  Comment:  The exact people who are most likely to benefit from a clinical trial are not getting to the point where they can make a decision, let alone participate in a trial.  Siminoff et al., J Clin Oncology, 18:6 (March 2000), 1203-1211.

Weekly docetaxel (Taxotere) administered on a weekly basis for patients with metastatic breast cancer was found to be active and also have a different side effect profile than a 3-weekly cycle of chemotherapy.   Comment:  Having fewer or milder side effects should improve quality of life for patients who choose this treatment pattern over 3-week treatment sequencing.  Burstein, J Clin Oncology, 18:6 (March, 2000), 1212-1219.