INTRODUCTION: The Topic of Cancer

Steve Osborn

Henry Miller’s infamous novel Tropic of Cancer is not literally about the disease known as cancer, but it does use cancer as a metaphor for Miller’s own despairing view of the world. As he explained later when asked about the title, “To me cancer symbolizes the disease of civilization, the endpoint of the wrong path, the necessity to change course radically, to start completely over from scratch.”

Unlike Miller’s novel, this issue of Marin Medicine is literally about cancer. Far from despairing, five local physicians offer mostly positive reports on medical progress against this pervasive killer. They describe encouraging steps in the detection and treatment of breast cancer, colon cancer, prostate cancer and lymphoma.

We begin with internist Dr. Joan Pont’s overview of cancer screening from a primary care perspective. While acknowledging that screening has proved effective for cervical, colorectal and breast cancer, Pont (an assistant physician in chief at Kaiser San Rafael) also observes that more work is needed to improve screenings for other forms of the disease. Cancer screening over the last 50 years, she writes, “is like putting hundreds of lights on a Christmas tree, then realizing that most of them don’t work and need to be removed.”

Kaiser gastroenterologist Dr. Jeff Fox furnishes a helpful overview of the half-dozen commonly available tests for colorectal cancer. While none of them is perfect, the buffet of options has lowered the incidence and mortality from colorectal cancer in the United States. Above all, Fox urges both patients and physicians to get screened. “There are few diseases,” he writes, “where modern medicine has been more successful than in preventing colorectal cancer.”

Unlike colorectal cancer, the incidence of Non-Hodgkin’s lymphoma continues to increase, a trend made all the more complicated by the bewildering variety of the disease, which has more than 30 distinct subtypes. In her article on new treatments for Non-Hodgkin’s lymphoma, medical oncologist Dr. Jennifer Lucas, who practices at Marin Specialty Care, focuses on two main forms of the disease. The treatments are diverse, but many involve the latest research in biologic approaches, some of which is being conducted locally.

Another local research effort is described by Dr. Mary Mockus, a Kaiser surgeon who serves as one of the principal investigators of the Marin Women’s Study, which includes representatives from the entire medical community. The study grew out of the discovery in the 1990s that Marin County had the highest rate of breast cancer in the United States. To date, more than 14,000 Marin women have participated in the study, whose first results were published in 2010. The study, writes Mockus, “is an example of the power of cooperation and collaboration.”

We conclude our cancer articles with Dr. Peter Bretan’s perspective on the ongoing controversy surrounding the PSA test for prostate cancer. A urologist in private practice in Novato (and president of MMS), Bretan urges continued use of the PSA test, despite the recent U.S. Preventive Services Task Force draft recommendation against the screening. While acknowledging that false positives on the test can lead to overtreatment, Bretan observes that, “Failing to administer the PSA test would sacrifice patients with undetected high-grade cancer, unbeknownst to them.”

Cancer can become all-consuming, but our departments cover a completely different range of topics, from frequent flyers to the German Resistance.

In “Keeping Frequent Fred out of the ED,” Kaiser emergency physician Dr. Dustin Ballard addresses the oft-returning patients who are placing an increasing burden on emergency departments. Like the patients themselves, the problem is complex, but Ballard details several potential solutions. “Given that frequent flyers take up such a significant chunk of ED time and resources,” he writes, “they are potentially a high-yield population for intervention.”

Another problem long in search of solutions is the ever-changing landscape of private practice. Jon Friedenberg, the chief fund and business development officer for Marin General Hospital, describes several new hospital-physician alignments that he believes will benefit everyone concerned. By coincidence, our rotating hospital update for this issue is also from Marin General. Dr. Susan Cumming, the hospital’s medical director, reports that the facility has launched several new initiatives, including a transition to electronic records and an effort to reduce readmissions.

Far from the hospital, Novato gastroenterologist Dr. Barbara Nylund writes about her recent journey to Sweden and Finland in search of her family’s roots.

Rounding out this issue is a review of the new biography of German Resistance leader Dietrich Bonhoeffer, whose struggles against the Nazis led to his eventual death in a concentration camp. He too was a victim of cancer, this one of human origin.

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Mr. Osborn edits Marin Medicine. Email: sosborn@scma.org