Issue: 83

January: Dump the Divisive "Wall" Metaphor!
I was counseled not to discuss this controversial topic but I can't resist!  Give the president credit for calling attention to our woefully inadequate border security and forcing Congress to take decisive action to enhance the safety of citizens living along our Southern border.  The unfortunate thing is that the " Wall" has become a metaphor for racial prejudice leading many in Congress to eschew border security for fear that they will be labeled anti-immigrant. Many of us were inspired by President Reagan when he famously said, " Mr. Gorbachev, tear down this terrible wall!" at the Brandenberg Gate.  We want no part in creating barriers to freedom. On the other hand, the sheer black wall at the foot of the Lincoln Memorial listing our revered Viet Nam dead has brought us together and healed gaping wounds in our social fabric.  It was a shame that just as we celebrated Martin Luther King's " I Have a Dream" legacy, the government was fighting over a mixed metaphor rather than the substance of immigration reform.  I hope for a win-win that recognizes the rights of immigrants and those legitimately seeking asylum, gives the Dreamers and those with Temporary Protected Status a path to citizenship, and secures our border even if it means erecting expensive barriers.  Let's ban the problematic metaphor that is dividing us and get on with building our immigrant nation into that " Shining City on a Hill", a "wall with doors" as Reagan put it as he bid farewell to the presidency and blessed the people of the United States.

John A. Schmidt, MD 
Cancer Survivorship
As beautifully discussed in the Dec 20th issue of the New England Journal of Medicine by Charles Shapiro, MD, the number of cancer survivors is growing rapidly thanks to advances in cancer treatment. In 2016, there were 15.5 million cancer survivors in the United States.  By 2040, there will be 26.1 million, almost ten per cent of the population!  Cancer survivorship is growing in all age groups, especially between the ages of 65-84, and it is high time that we begin to focus not only on those who are fighting cancer but those who have survived the ordeal.  The major message: There is life with cancer and after cancer and we need to improve the quality and quantity of that life! 

Anecdote: I once said to our beloved oncologist daughter,  "I tell my patients to declare war on cancer before it kills them." She was horrified and said, "Dad, It's not a war!"   Mea culpa, Mea culpa.

Here are some gems from Dr. Shapiro that I think our daughter would agree with:

"Included in the definition of survivors are family members, friends, and caregivers.  The primary reason for including these persons is that cancer is not experienced alone.  Caregivers are the unsung heroes, providing physical and emotional support to the cancer survivor."  "We need to recognize the adverse health effects and emotional toll on caregivers."

Surveillance for recurrence is sometimes indicated but not always. Surveillance for recurrence causes distress and patients deserve to know why continued surveillance testing might be helpful.  As examples, he points out that surveillance for recurrent breast cancer does not save lives whereas surveillance for recurrent colon cancer does.  Also, surveillance should include cancers that might result from the initial cancer treatment.  For example, prostate radiation can predispose to bladder cancer.  I am therefore always on the lookout for hematuria in my prostate cancer survivors who have had radiation.

"All persons with potentially curable cancers should have the recommended sex- and age-specific routine screening tests that are recommended for the general population (e.g. colonoscopy, mammography, Pap smears and HPV testing, DEXA, vaccinations, and screening for hypertension, diabetes, and lipid abnormalities." I was really happy to see this recommendation because I am so used to my survivors remaining so fixated on their cancer that they forget to take care of everything else!! Stay holistic!! 

Some cancer treatments have potential long term negative effects. For example, treatment with hormonal therapy for breast cancer and prostate cancer can have detrimental effects on bones.  Such patients need to be screened for accelerated osteoporosis and treated with bone-strengthening medications if bone density declines to unsafe levels.

"Weight management, increased physical activity, a healthful diet, smoking cessation, and reduced alcohol consumption are the foundation for improved health for everyone, and especially for cancer survivors." Amazingly, "cancer survivors are no more likely to quit smoking that the general population."

"Depression and anxiety, post-traumatic stress disorder (PTSD), fear of recurrence, and return-to-work and financial issues are among the psychological consequences of living beyond cancer."  Many cancer survivors experience distress that can be quantified using an instrument known as the NCCN distress thermometer that has been labeled the "sixth vital sign". If you are a cancer survivor, please use the tool before your next appointment so we can discuss the results.

"Older cancer survivors may not have the same goals as younger adult survivors.  For younger patients, prolonged survival may be the primary goal, whereas older patients may value independent functioning and preservation of cognition over length of life."  " Geriatric 8 is a tool that helps assess frailty, the likelihood of treatment-related side effects, and the potential for death."

"80% of childhood cancers are cured but many suffer from second cancers and treatment related conditions."  "Adult survivors of childhood cancers have significant declines in functional status, increased limitations on activity, poorer mental health status, and poorer general health than a matched sibling control cohort." "Common problems of adolescent and young adult survivors are infertility, other reproductive problems, and psychosocial issues."

"The problems that caregivers and cancer survivors have are strikingly similar.  Fatigue, insomnia, loss of physical strength, loss of appetite and weight, depression, anxiety, PTSD, and lost income are some of the problems associated with caregiving."  "Cancer caregivers are woefully underserved and yet essential as more cancer care is home-based."

"Cancer survivors receive the highest level of care if they see both an oncologist and a primary care provider." This is the most important point in the entire article. It is my responsibility to work with you, your caregivers, and your oncologist to make sure that all of your survivorship needs are met!!
Parkinson's Disease: No Drawback to Starting Treatment Early!
Parkinson's is a common neurodegenerative disease.  Patient's often develop a tremor in one or both hands described as "pill rolling".  They may have difficulty getting up from a chair without using their arms.  They become stiff.  As the disease progresses, their hand writing gets smaller, their speech becomes softer, they loose their facial expression and begin to shuffle.   Dementia and labile blood pressure can occur as the disease progresses.

Parkinson's is due to a deficiency in a key neurotransmitter known as dopamine.  Patients are therefore treated with a dopamine precursor, known as levodopa, and/or dopamine agonists. Levodopa is almost always given in combination with carbidopa which prevents breakdown of levodopa so that more reaches the brain.

Neurologists have wondered if giving levodopa/carbidopa slows the progression of Parkinson's, that is, has a "disease modifying" effect or simply provides symptomatic relief without altering the natural history of the disease. 

This question was recently addressed in an important study from the Netherlands published in the January 24th issue of the New England Journal of Medicine.  Half the patients were treated with levodopa/carbidopa early while the other half were treated after waiting 40 weeks.  After 80 weeks there was no difference in symptom score between the early and late start groups indicating that the medicine had no disease modifying effect. Similarly, the rate of progression was the same in both groups.  The editorialist concludes, "This trial supports current practice.  There is no evidence that early initiation of levodopa slows progression of the disease; on the other hand, there is no reason to delay therapy when it is clinically indicated.  The results...support treatment that is guided by clinical need and that uses the lowest dose that provides a satisfactory clinical effect."
Progress in Treating and Curing Sickle Cell Disease!
Sickle Cell Disease is a disease that afflicts persons of African descent.  It results from a single point mutation in the gene that encodes the beta chain of hemoglobin, the vital polymer inside red blood cells that carries oxygen to tissues. While the mutation results in the replacement of only a single amino acid, the resulting " Hemoglobin S" has vastly different properties that cause it to form rod-like bundles which make red blood cells less deformable and "sickle" so that they get stuck in capillaries, thereby blocking blood flow and causing excruciatingly painful " sickle crises" or worse.

Babies make a different beta chain that competes with the mutant chain to form " Hemoglobin F," also known as fetal hemoglobin. Fetal hemoglobin does not sickle.  Treating patients with a drug known as hydroxyurea increases the production of Hemoglobin F long after production of hemoglobin F would normally be turned off in the bone marrow of the maturing child. Patients who make large amounts of Hemoglobin F in response to hydroxyurea have far fewer crises but the response is variable and hydroxyurea has toxicity issues that make its long term use problematic. 

As reported in the Sunday  New York Times on January 27, we are closer to a cure for Sickle Cell Disease than ever before.  The cure involves harvesting bone marrow stem cells from patients with Sickle Cell Disease and inserting genes that express beta chains that, like the fetal molecule, block sickling. The engineered stem cells are infused back into the patients where they produce red blood cells that can squeeze through capillaries without sickling. These results follow on the successful CAR-T work at the University of Pennsylvania School of Medicine and Children's Hospital of Philadelphia where normal T cells harvested from cancer patients are reengineered to express modified T cell receptors and then infused back into patients to kill tumor cells and cure cancers.
Now Hear This!
Valerie, Carol, Ms. Clark, Ms. Catong and I are committed to helping our patients who have cancer and have survived cancer.  I am a cancer survivor and so is my dear wife. Valerie also has a loved one with cancer.  Let's stick together and beat cancer!  No war, I promise!!  Only caring!  
In This Issue
January: Dump the Divisive "Wall" Metaphor!
Cancer Survivorship
Parkinson's Disease: No Drawback to Starting Treatment Early!
Progress in Treating and Curing Sickle Cell Disease!
Now Hear This!
John A. Schmidt Jr., M.D.
Board Certified Internist
Dr. Schmidt is one of the leading internists in Monmouth County offering  Medical Home services.  
He is an attending physician at Jersey Shore University Medical Center.
Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine
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- Ronald Reagan


John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
2006 Highway 71, Ste. 3, Spring Lake Heights, NJ 07762
Phone:  732-282-8166  
Fax:  732-280-0147 
Disclaimer: The articles in Healthy Living are for general information only and are not medical advice.
Discuss all medical concerns and treatment options with your physician.