Friday, January 23, 2009

"Oh teachers are my lessons done? Leonard Cohen

I cannot do another one.

They laughed and laughed

and said, Well child,

are your lessons done?

are your lessons done?

are your lessons done?

Leonard Cohen

My teaching on the abstracts from ASH went well. There was much lively discussion on why results in studies done at the fancy universities seem to have consistently higher response rates than those done in community based practices.

None of the answers are comforting. Are the big centers cherry picking their patients? Is care in the community inferior?  In truth, comparing one study to another is bad science. Doses and protocols may vary. Inclusion criteria and patient mix can make big differences in outcomes. Most older studies did not look at the new prognostic factors. Still it is worrisome. MDACC gets a 72% complete response rate and the community oncologists only help 17% of their patients to reach that desired goal with the same drug combo. Something is wrong here.

We also discussed the sad fact that there is still no evidence we are prolonging life in CLL, let alone curing it. Except maybe for a stem cell transplant. Which is why I made that choice. No regrets there. The new drugs reminded me of buying a house with lots of potential. They look so promising. So much potential. And yet the patients aren't living any longer. How's about some realization of all this potential.


That would be sweet. 

I will write some straight science soon from my take on ASH, but I will make it bite size and comprehensible.

For a tired guy on disability, I want to share with you just a tiny bit of the "work" I did this week. Forget the doctor's appointments and other commitments.

I reviewed a research project from 2005 on migraines, pulling up old data at the request of principal investigator.

I pulled and reviewed data on the epidemiology of cancer and transplants for my book.

I got copies of my old medical publications, again for my book to impress the potential agents. If they ask why the 30 year gap in publication, I will say I was busy.

I am preparing my writing sample and introduction for the book conference in early Feb.

I reviewed a proposal for a focus group to improve CME (continuing medical education) that I would moderate.

I researched second transplants in CLL. I can't find any papers!

I researched experts in second transplants and DLIs and CLL and began to try to make contact.

I reviewed a joint research proposal with Purdue University that may feature this blog.

I responded to medical questions online from everything from CLL to earwax to contraception. Honest!

I registered for two CME lectures for myself (CLL and gout).

I prepared the lecture for my colleagues in oncology, including getting copies of all the abstracts to them in advance of the meeting.

I also got a new cell phone (my old one died), a new external hard drive for backup (my old one misbehaved) and a new bluetooth speaker (my quite new one was DOA) for the car, all of which had some learning curves and set up hassle.

Who has got time to be sick? 

I may slow down again on the blog for a week as I need to finish some other writing, but I will be back.



Blogger Mikha'el said...

Amazed by the schedule you keep and sounds like life is good. Look forward to your book and further adventures.

January 24, 2009 at 12:02 PM  
Blogger T said...

I just recently found your blog, and I love it. I like your perspectives as a physician and a patient. As an RN, I quickly learned, after my CLL diagnosis, that what is best for the practitioner is not necessarily best for the patient.

I was diagnosed at the time when MDACC released their results of the FCR protocol. Although I was very much aware of how researchers can "manipulate" statistics, selection criteria, etc., the study gave me hope (probably because I needed it). After reading peoples' experiences on various forums, I began to question the validity of the reported remission rates when they didn't seem to match actual patients' experiences. I believe the differences in results between studies is probably a combination of the factors that you sited although the discrepency is even greater than I would have imagined.

I have also been dismayed that no treatment has been shown to increase life expectancy. I am not understanding the use of more toxic and immunosuppressive protocols when it appears the outcome is the same regardless of the therapy used. Can you shed some insight on this?

Being diagnosed at age 45 and unmutated, a transplant is in my future. Thanks for paving the way, and thanks for sharing your experiences with the rest of us who will be following in your footsteps.

January 25, 2009 at 9:45 AM  
Blogger Brian Koffman said...


Thanks. Stay in touch. My email is

You ask why the toxic treatments. Good question. You don't want the treatment to be worse that the disease, hence the guidelines on when to treat. If you are not having problems or are just about to have problems, stay away from treatment. If you are in trouble from anemia or painful nodes or a host of other issues, then the risk/benefit ratio may shift in favor of the meds. And most are toxic, but the toxicity is usually manageable.

The one exception being explored is whether early treatment can improve outcomes in high risk patients before they have problems. The answer is years away.

Hope that helps

Be well


January 25, 2009 at 4:22 PM  
Blogger CLL SPOUSE said...

A 30-yr gap in publication will not be an issue unless your next book (after the one you are proposing now) will take another 30. :-)

January 26, 2009 at 4:52 AM  
Blogger Judy Cleri said...

Hi Dr. K,

For some reason I am no longer getting your udates. I have registered again, but no luck. So, it is hit and miss as if I rememeber to check your site.....old age...what can I say?

Not sure how you are keeping up with everything. I take my hat off to you. But there again, you were always one step ahead of us all.

Well, I hate to say it, but my poor Ducks are almost out of the race. They are playing like a high school dteam right now. But the good news is your Kings are stepping up the pace. Maybe this will be your year.

Prayers and thoughts are with you. Looking forward to your next post.


January 26, 2009 at 10:47 AM  

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