Review of How We Do Harm by Otis Brawley and Paul Goldberger

In America, there is an underlying assumption that medical professionals placing their patients care above all else. We believe that our physicians follow important concepts such as the principle of beneficence, and the principle of nonmaleficence. Yet in the book How We Do Harm, Brawley introduces his readers to the back rooms and the unknown conversations of those in who are a part of the medical profession. This insiders perspective is Brawley’s (and his co-author) real genius, the ways he makes makes what could otherwise be an esoteric and dense topic become an enjoyable book.

Though a joke about how important money is to the american medical system A Wallet Biopsy, its one that is important because if you can afford the best care,get the best care. If however, you cannot get good care, you get the a bare minimum of care. Yet Brawley does not make this a purely socialist critique. In many ways, Brawley acknowledges that wealth can cause its own problems in America. Patients with sufficient wealth often demand treatment that borders on irrational, and for those with means finding a doctor willing to satisfy their concerns is not hard. The reason for this treatment seeking behavior, is that the American healthcare system is not design to prevent elective treatments which are not only not necessary but also often quite expensive. Yet the doctors are not dupes and the reason why there is always a doctor willing to give into to the demands of patients providing they can pay the costs.

Yet at the same time Brawley is not seeking to place physicians on a pedestal who can do no harm. Brawley introduces us to two different but equally heartbreaking cases Helen and Lillia. Helen’s story is a used has an exemplar of the “more is better” philosophy Brawley sees as endemic in the medical community. After having a mastectomy lump, her oncologist She was “offered” post surgical chemotherapy. Her oncologist explained that a stronger dose is better than a weaker dose. “More is better” notes Brawley had been the fallback strategy for oncology since the 1950s with the general opinion being that , more chemotherapy translated to greater the more effectiveness. Yet for Brawley this approach is not the real tragedy of Helen’s story is that she was recommended a autologous bone marrow transplantation since her insurance company will pay for more of the costs of the transplant and chemotherapy (page 32). As a result of this treatment, Helen experienced far more severe complications than expected and ultimately these complications kept her in the hospital for five months and is then transferred to a rehabilitation hospital. Taken altogether this “recommended” procedure cost her a year of her life. Then three years later, Helen discovers that this painful experience had no demonstrable effect in improving survival. When Helen asked her oncologist , her oncologist responds “this was what everybody was doing at the time.” Brawley does points out that Helen is not alone as between 1989 and 2001 at least 23000 women might ha

In the second case, Lilla Romeo was first diagnosed with breast cancer (Stage 1) in 1995. She had surgery followed by radiation. Five years after the initial diagnosis, a routine scan (how many scans did she have in the 5 years?) showed the disease had returned. The doctors told her that “the prognosis turned grim…the cancer was incurable, and the goal of treatment was to delay the inevitable.” So Lilla was persuaded, and started non-stop chemotherapy (page 71).

In 2003, Lilla remembered an oncology nurse at the New York University Medical asked if she was feeling tired and with a hemoglobin reading just under ten, she was “suggested and offered” cancer-fatigue drugs (at that time, the popular one was Procrit by J&J)

In 2004, she was told that the hospital had switched from Procrit to another drug, Aranesp (manufactured by AMGEN), which caused a burning sensation under her stain at the injection site (page 79).

In 2010, when she requested copies of her medical records from the doctors who had treated her, Lilla learned that she had received a lot more Procrit and Aranesp than she knew. Her first dose was administered on 1/11/2001 and then almost weekly thereafter. Altogether, she was given 221 1/2 doses.

When Lilla was started on the hemoglobin-building drugs (also known as ESAs), little did she know that the drug companies manufactured a medical condition: cancer fatigue. She also had no idea that “her infusion was the front-row seat for observing a spectacular, indeed, cataclysmic, failure in medicine.” Dr Brawley strongly believed that these drugs have shortened Lilla’s life. She died on June 9, 2010 at the age of 63 (Just before her death, Lilla was suggested and given “Avastin”!!)

Finally, there is the case of Ralph DeAngelo, who was prescribed aggressive prostate cancer treatment after a positive prostatic specific antigen (PSA) screening. Unfortunately for Ralph DeAngelo, PSA screening has lead to financial gain to many medical businesses, but Ralph DeAngelo ended-up incontinent, sexually impotent, and with a rectal fistula into the bladder (Brawley & Goldberg, 2011, pp.215-230).

It was very eye-opening to find out that physicians may sometimes prescribe experimental drugs to patients with little or no detailed information or informed consent about the potential side effects and the eventual lack of thorough trial studies on a given drug. It was also sad to be reminded that the American healthcare system lacks good use of its resources. This is particularly true for the “working-poors” who lack proper access to healthcare. By the time they qualify for Medicaid, they are so sick that their situation is so dire that it’s likely to have a negative outcome. Finally, it was disconcerting to find out that physicians may prescribe some expensive and potentially harmful screenings to patients for their sole financial gains.

Part III: Corroboration.

Studies have shown that despite the advances made in the war against cancer, there are many disparities in the delivery of care, based on factors such as race, income, and geographic area. Many patients report problems such as lack of insurance, high co-payment for prescription drugs and transportation issues. In addition, African-Americans are more likely to be diagnosed of advance stage cancer than Caucasians (Schwaderer & Itano, 2007).

In addition, despites their widespread use, some screening tests such as the PSA have shown some limitations. About 75 percent of positive PSA test are false positive, which may be associated with psychological harm more than a year after the test. In addition, diagnostic testing and aggressive treatment of a non life threatening prostate cancer may result in adverse consequences such as erectile dysfunction, incontinence, and even patient’s death (Slatkoff, Gamboa, Zolotor, Mounsey & Jones, 2011).

Shortly after he turned 70, Mr. Ralph De Angelo, a retired department–store manager in the heart of black America, saw a newspaper advertisement that claimed that prostate cancer screening saves lives. The advertisement also mentioned that 95% of men diagnosed with localized disease are cured.

The following is the tragic story of Mr. De Angelo after his prostate screening and how unnecessary harm can be done to those who go for screening of the prostate, breast, etc. This is a classic example of collateral damage (due to overtreatment) described in the book “HOW WE DO HARM” by Dr Otis Webb Brawley, MD a medical oncologist and Executive Vice President of the American Cancer Society.

In 2005, Mr. De Angelo, after his prostate screening, was diagnosed with prostate cancer, with a PSA reading of 4.3 ng/ml (just 0.3 above is considered normal). He was urged to have a biopsy. Two of the 12 biopsies showed cancer. The Gleason score was 3 plus 3 which is associated with the most commonly diagnosed and most commonly treated form of prostate cancer. There is no way to know whether a patient with this diagnosis will develop metastatic disease or live a normal life unaffected by the disease.

With this uncertainty, Mr. De Angelo was persuaded by his urologist to perform a radical robotic prostatectomy which he (the urologist) thought was the gold standard of care. After the operation, he was told he had a small tumour 5mm by 5mm x 6mm in a moderate size (50cc) prostate. The tumour was all in the right side of the prostate. This means that the tumor didn’t appear highly aggressive under the microscope. Good news? Unfortunately, Ralph realized that he was then incontinent. Three months later, the incontinence was still there and he had to wear pampers continuously. Besides incontinence, Ralph was also impotent and given Viagra.

With a lingering 0.95 ng/ml (even though his prostate has been removed), a radiation oncologist suggested “salvage radiation therapy” to the pelvis. Four weeks into the radiation, Ralph saw blood in his stool. This was due to radiation proctitis, i.e. radiation damage to the rectum. He continued having incontinence, but also developed a burning sensation upon urination. Later, Mr. De Angelo stopped his radiation with one more week to go. For the rectal proctitis, he went to a gastroenterologist, who prescribed steroids in rectal foam that he had to put up his rectum four times a day.

About three weeks after stopping the radiation, Mr. De Angelo realised that whenever he passed gas, some of it came out of his urethra. He also sensed liquid from his rectum soiling his diapers. He was confirmed having a rectal fistula into the bladder…there was a hole between Ralph’s rectum and his bladder. After several urinary infections and when the fistula didn’t seem to be healing, he had to see a GI surgeon. He performed a colostomy to keep stool off the inflamed rectum and the hole into the bladder. The next step was an ureterostomy, a surgery that will bring urine to abdominal wall and collect it in a bag, just like his bowel movements.

In Dec 2009, Mr. De Angelo’s daughter called Dr Brawley to inform that her father had “urinary tract infection” which later progressed to sepsis, a widespread bacterial infection in the blood. On the fifth day of hospitalisation, Ralph passed away (only 4 years from diagnosis). Interestingly…”the death certificate reads that death was caused by a urinary tract infection. It doesn’t mention that the urinary tract infection was due to his prostate-cancer treatment and a radiation-induced fistula….Mr. De Angelo’s death will not be considered a death due to prostate cancer, even though his death was caused by the cure.

In conclusion, Dr Brawley strongly believed that… “the majority of these men, who are treated with radiation or hormones or both, got no benefit from treatment. They get only the side effects including those that Mr. De Angelo had: proctitis i.e. inflammation and bleeding from the rectum, cystitis, burning sensation on urination and a feeling of urgency, a rectal fistula in which bowels and bladder are connected. The side effects of hormones can be diabetes, cardiac diseases, osteoporosis, and muscle loss.

In the case of Mr. Ralph De Angelo, both the surgeon and the radiation oncologist got paid handsomely. They both likely thought they were doing the right thing. However, Ralph got the side effects, and his quality of life was destroyed (too much collateral damage?).

One parting remark by Dr Otis Webb Brawley which is very relevant to this article:

“Prostate-cancer screening and aggressive treatment may save lives, but it definitely sells adult diapers “

Part IV: Practice Application.

After reading How We Do Harm, I think that it would affect my nursing practice in many ways. As healthcare professional, this book reminds me of the importance of staying current with my nursing knowledge through continuing education, and reading resources from organizations such as the Mayo Clinic, the American Nurses’ Association and the Center for Diseases Control and Prevention. In addition, as patient advocate, this book reinforces my desire to empower all patients under my care, so that they may be active partners in their healthcare. More than ever, I will encourage my patients to educate themselves on their diseases; in addition, I will encourage my patients to learn more about all treatments options so that they may make the best choice for their healthcare.

How American Medicine Does Harm To Patients

• With powerful incentives set in motion, many hospitals and oncology practices in the US instructed nurses to ask leading questions about “fatigue” with the intent of expanding sales to a growing number of patients and upping the dosage to each patient. This is referred to as “an ESA treatment opportunity” (ESA means erythropoiesis-stimulating agents, drugs used to overcome fatigue, low blood counts). (page 85).
• To increase their earnings, drug companies and doctors set out on a search for treatment opportunities, often forgetting about the sacred trust between doctors and patients (page 85).
• The exact magnitude of harm is harder to gauge…most of the money was spent on drugs (e.g. ESAs) that were prescribed for the wrong reasons and under false, manufactured pretences. These drugs were not used to cure disease or make patients feel better. They were used to make money for doctors and pharmaceutical companies at the expense of patients, insurance companies…the technical term for this is overtreatment and overtreatment equals harm (page 97).
• Doctors do some horrible, irrational things under the guise of seeking to benefit patients….For example offering a bone marrow transplant for a breast cancer patient, prophylactic doses of ESA drugs…these are only a few examples. The system rewards us for selling our goods and services, and we play the game (page 122).
• You don’t deviate from the science. You don’t make it up as you are going along. You have to have a reason to give the drugs you are giving. You have to tell the patients the truth (page 145).
• Commenting further on ESA drugs, some doctors didn’t bother to check what the patient’s haemoglobin was and erred on the side of giving the ESA every time they give chemotherapy. Doctors routinely prescribed the drugs for uses, in which it had not been studied-such as anaemia caused by cancer itself, as opposed to anaemia caused by chemotherapy (page 78).
• ….Doctors try out things just to see whether they will work (page 160) Earlier in the book (page 29), Dr Brawley mentioned that “A hospital was the place where they withheld treatment or where they tried things on you without telling you what they were doing and why (page 29/30).
• When a drug succeeds in controlling cancer, we learn about it at conferences and in scientific journals. Stories of our fiascos, though no less instructive, are almost invisible, especially if there are cautionary tales that lay bare the fundamental flaws in the system (page 157).
• Cancer is hard to understand, and yet doctors rush patients (page 182).
• Survival measures time that elapses after diagnosis. By diagnosing a cancer earlier, survival rates are increased. The more you diagnose, the more you push up survival (page 193).
• Somewhere along the way, we have been conditioned to believe that a new treatment is always better (page 197) A new drug must be better than the old. A new medical device must also be better (page 202).
• Inappropriate use of certain drugs can be attributed to the profit motive. A recent study of prescribing pattern demonstrated that as soon as the profit motive weakened, inappropriate prescribing of these drugs dropped (page 197).
• The overuse of radiologic imaging is a major problem…..”up to one-third of radiologic imaging tests are unnecessary. This is a serious problem, not just because these tests are expensive, but because they expose the patient to radiation that can cause cancer. Some have estimated that 1% of cancers in the United States are caused by radiation from medical imaging” (page 202).
• Even when administered properly, cancer drugs can bring the patient to the brink of death. An overdose can easily push him off the cliff (page 279).
• Much of the money currently spent on healthcare (in the US) is money wasted on unnecessary and harmful, sick care. Even for the sick, a lot of necessary care is not given at the appropriate time. The result is more expensive care given later (page 281).
• The medical profession frequently allows bad doctors to continue to practice. The profession doesn’t police itself. Chalk it all up to apathy. Or ignorance (page 282).
• Many physicians are ignorant of some aspects of the field of medicine in which they practice. They tend to think the newer pill or newer treatment must be better because it is new. Ignorance is a failure to think deeply. It is a failure to be inquisitive. It is a failure to keep an open mind (page 282).

Dr Brawley’s most direct critique of our healthcare system “.”America does not have a health-care system. We have a sick-care system”.