Cancer Treatment Radiation

>> we look at the strides we've made against cancer and where we need to keep working. modern cancer treatments tonight, "on call with the prairie doc." >> good evening, and welcome to "on call with the prairie doc." we've come a long way in our efforts to counter the many forms of cancer that exist. what was just a few years ago a death sentence may now, in many cases, have an effective treatment to help patients become cancer free. tonight we'll look at causes and treatments of this terrible disease. first, let's take a look at this week's prairie doc quiz question.

according to a report from the national institute of health, cancer institute, "since the early '90s, the death rates for cancer continue to... a, decline or b, increase. we will give the answer at the end of the show. joining us tonight is dr. benjamin solomon of avera medical group oncology & hematology. dr. solomon is also assistant professor of internal medicine at university of south dakota sanford school of medicine, and medical oncologist with the avera cancer institute. also with us is kyle arneson, m.d., ph.d, a radiation oncologist at avera cancer institute.

kyle, let's just start with you, tell us a little bit about what brought you to go into radiation oncology? >> yeah, so radiation oncology is kind of a mysterious part of medicine. what we do in our clinic is very different than from a person normally thinks of as medicine, normally the primary care doctor. >> right. >> it's a ability to help treat cancer and treat it with beams of energy. it is a fld that is very technologically advancing. we get to play with technology tools, toys, and we're getting better as far as how we deliver that radiation in the safest manner possible.

>> but see, now, just this last week i was writing an essay about x-rays and they said they're similar, they're too late although just shorter and maybe more powerful, and then so is gamma radiation. can you explain that a little? >> yeah, so radiation is a beam of energy, just we're using beams of energy that are tailored to be able to kill cancer, they're able to be able to deposit energy within that cancer cell to cause damage that will lead to that cell dying. we're able to pick and choose whatever energy we use and deliver it precisely so we can provide that cancer-killing benefit.

it is many different forms of radiation that we use, x-rays are very common, gamma rays are common, we also use electrons and protons and sometimes even neutrons in rare cases and it's all about trying to get the energy where it's supposed to be so we can eradicate the cancer. >> are you involved with some of the surgeons where they place a radioactive pellet of some kind in a breast cancer, for example? >> yes. so many ways to deliver radiation, often it is with beams of energy but oftentimes it's using a radioactive source.

so you work closely with a surgeon. i think one of the more common treatments that we think of is prostate seed implants, where tiny pces of radioactive material are placed inside the prostate, deliver strong radiation but only for a short distance so you're able to treat the prostate while keeping the radiation confined within the gland itself. >> so the idea that i have is that you have a beam that goes in this direction and then you either rotate the beam or you rotate the patient so that the beam concentrates on that tumor

and is less concentrated in all the rest of the body, so the rest of the body isn't as affected. now, is that a way of explaining it? >> i like that explanation.i could probably clarify a little bit more on that. with radiation treatments, it's all about identifying where the cancer could be or where the cancer is, and making sure that's where the radiation goes. when you design radiation, you have to get the radiation to the cancer and then the question is how can you better spare those good tissues that are nearby? and there's multiple ways that you can bend and shape that radiation, some of it has to do

with maybe how the patient is laying for treatment. some of it has to do with what technology or machine you're using to try to get the radiation in there and, you know, there are advantages to perhaps using many different angles so that you never have to have that strong radiation on a good, healthy tissue that maybe gets a lower amount which would be safer. >> now, ben, you're an oncologist or cancer therapist as a rule but what i see you as a general internist that knows all parts of the body, like i do, but you also have those formulas for which to treat people with cancer. what drew you to go into oncology?

>> for me it was always patient relationships, quite honestly. i enjoy long-term relationships with patients. i enjoy getting to know them and their families and i kind of like hearing the beginning of the story, the middle of the story and the end of the story, and there are many flds in medicine that maybe you get to hear the beginning but not the end, or you hear somewhere in the middle and i just liked being involved from the very beginning with patients, and i found that patients with cancer can be pretty inspiring and the

cases that i had in my training of patients with cancer were those that i really remembered a lot, and that's really what hit home most for me, really. >> my sense as a geriatrician is that i help people at the end of their lives, as they come to the final point. and you oftentimes do the same thing in many ways, but many times the patient is younger. how hard is that? somebody says it's a sad fld. how do you feel about that? >> you know, there are times when we are challenged by difficult diagnosis or maybe a young patient that everybody thinks they're too young

to have that disease and that is part of what we do but i always come back to the idea that we -- i feel like i always help people, whether it's helping them to -- with curative intent treatment, whether it's helping them understand the difficult diagnosis and prognosis, whether it's -- >> and what does prognosis mean? >> that means an estimate of how well a patient might do with their diagnosis. so oftentimes people think about how long a patient might live but that can -- prognosis can really be more short-term in terms of how likely are we to control the disease where it

sits right now, or things like that. but, you know, we help people to understand things about their cancer, and i find that to be rewarding, and so that's one of the things that i come back to. and i come back to the cases that i did feel like we had accomplished a lot and that really kind of helps to energize me. from some of those cases that are maybe more of a challenge because we do have challenging case that is we see. >> people kind of blame you for their cancer sometimes?

>> i think that sometimes people are searching for an answer to why did this happen to me? you know, i do hear patients say, you know, i didn't smoke, i ate well, i exercised my whole life, i'm 55 years old and now i have advanced cancer, you know, and there is that sense of sort of "why me." so i do think sometimes there are patients who have a point of view at some point in their care that maybe the world is out to get them but i find it sort of a challenge and rewarding when i can sort of win those patients over and

help them to understand what's going on, and understand that it's really not their fault. we know a lot about how cancer develops but generally we know that no one ever chooses it. >> no, and it is not ever anybody's fault, really, is it? >> correct. i often >> i often think about smokers, well, it's your fault they smoked and many of those cancers have nothing to do with their smoking, so we don't blame anyone for that. >> no, absolutely. the thing i remind people, we see patients who have had some exposure that probably increased their risk of them developing the cancer but,

again, we don't need to be dwelling on what's happened in the past when we're dealing with what we're dealing with in the now. >> in the now, exactly. so to the both of you, if i were going to talk to ten lay people about cancer therapy and cancer treatment, i'm going to have some people who are going to be saying that those guys don't know when to quit. probably the biggest criticism i hear is, they use their tools and they're not listening to the patient and they're not looking at the prognosis well enough and they don't know when to quit.

do you sense that that occurs much? is that a fair criticism and are we doing better? let's start with that.is that a fair criticism? it's a fair criticism but i think everyone is striving for that not to be the case. we have patients that are, you know, fighting cancer, they're on a cancer journey. for some patients, the journey is i'm diagnosed with cancer and i'm going to be cured with a surgery or radiation or chemotherapy, and then their journey is, it isn't the cancer anymore but the potential changes to their life now that they've been cured from cancer and the treatments that they had.

some of the patients' journey is that they, you know, have been fighting cancer, maybe it was cancer that came back, maybe it was a cancer that wasn't curable when it was first diagnosed, and what is so hard is knowing how much time someone is on earth. no one here at this table knows how long, each when we prognosticate and give patients data or statistics, that is not specific to them, that is just our, you know, kind of, you know, guidance.it's trying to come up with what treatment plan can provide benefits, quality of life, you know, help with the symptom, but it is also then understanding the patient's trajectory.

as someone fights cancer, the fight becomes harder. it becomes harder because the cancer may be getting stronger or maybe because the person is getting weaker because of the cancer treatment that they had. and sometimes the hardest part about working with a patient with cancer is having the conversation about when should we quit. and patients don't always want to quit. and that's hard for the physician, too. >> sometimes they should quit and it's hard to say "time to quit." your response that question about bad rap? >> when i talk with patients, i always talk to them about

crossroads where we make decisions, so that's kind of my analogy. we come to a crossroads and we need to turn left or turn right, okay? and at every point in the treatment course, you know -- i should say at multiple points during the treatment course, they come to crossroads where we need to make a decision, are we going to choose -- maybe there's three choices, going to choose treatment a, treatment b or not treatment, and i try to talk to them about that at every point, or most points along the way. sometimes it's a no-brainer that we're going to treat but

there are other -- there are a lot of cases where we need to kind of start to ease them into an understanding that at some point there won't be another treatment potentially, and so, you know, that i think is one way that i try to -- i do think it's a fair criticism and i think, you know, physicians by our nature, i think we want to help people and sometimes in helping people, we get a little caught up so we do have to take a step back at times and say, okay, is this really in the patient's best interests or not? and that's what kyle and do i on a regular basis is,

is it time to treat or is it time not to? and those are hard decisions to make with patients. >> and ultimately, they all are the ones who make the choice. we don't make the final decision. yes, i will go down road b, they make that choice. >> we're charged with making recommendations. >> that's it >> and i think we do our best to do that. in the ends, it is a recommendation and it's their call, yep.

>> yep. even when you're getting treatment for cancer, you still try to carry on with your life. however, there may be some specific adjustments you will need to make. >> i had a small lump and it didn't go away. in fact, it continued to grow until i decided i should have somebody check it. and my doctor felt it a couple of times and we kind of thought maybe it was just a cyst, it was in kind of an unusual spot, so as it got bigger, i didn't like it cosmetically and i was concerned about it. and so had it biopsied and that came back negative.

so we weren't too worried, but finally it got big enough that i didn't like the looks of it so we decided to have it removed and when they removed it, and tested it, it was malignant. they called it salivary gland cancer, it was right up here on the side of my face, right in front of my ear. and it was a pretty good-sized lump there. they said it was, you know, the size of a good-sized marble or -- not as big as a golf ball but there was a pretty good lump there and they removed that, and then when they determined that it was cancer, in another week or so, i had a

second operation and removed all of my lymph nodes. the radiation, they said it scatters. i have some dental work over here, a couple of crowns, and the metal in your mouth apparently makes it worse in your mouth. it burnt quite a good-sized hole in the side of my tongue and if you've ever had a canker sore, how bad those are, this thing was like, you know, 100 canker sores. they were doing a routine p.e.t. scan, checking for cancers anywhere else and i had some spots in my lungs and so

they treated -- i had a biopsy on those and they were cancer. and i had those treated with radiation, just a pinpoint radiation that they can shoot in there with those little tumors, they were small, but they shot this radiation in there and that was just back here in may and, at the time, it was actually my busy season for my business and i worked right on through it. i think attitude is probably 50% of it, 80% of it. i just assumed i was going to live through it, so i don't know if i ever had a down day where i thought this is not worth the effort.

i don't think that ever entered my head. i just knew i was going to be okay. >> well, thank you for that, brian, and the history of that, so a tongue and 100 canker sores really worries me. could there have been something done differently on radiation therapy? >> radiation therapy, any time you're in the head or neck region, it's a really hard treatment. it's a hard treatment because the tissues there, we depend on them every minute of the day, be it for swallowing, talking,

breathing, and the side effects when the radiation does cause them are ones that do, you know, really, you know, affect people for the rest of the treatment duration and for several weeks or months after. there's ways that you try to bend and shape that radiation but ultimately, in order to provide the benefit, you need that radiation where the cancer was. so, you know, there are some tricks up our sleeve but sometimes, you know, we have to help the patient through the side effects because that's how we know we're going to provide the benefit. >> so is it better now, though, than it used to be?

>> yeah, you know, just -- knowing where the radiation should go based on the staging work-up, doing p.e.t. scans and mris and c.t. scans, before we start the treatment, knowing what these beams of energy can do, you know, what are their properties, how can you get the treatment there while trying to spare that normal tissue? you know, there's -- we're making great leaps and strides but unfortunately, we still have patients -- we ask them to take on a burdens of side effects, both short term and long term, to try to provide that cure. it's hard, it's hard.

>> any comment about this case, ben? >> i would agree with kyle about the challenges associated with head and neck radiation as well as just the entire regimen that we often work together on. so many of these patients, not all but many also receive some chemotherapy associated, basically, during the radiation course and i try my best to be optimistic about the intended outcome, which is cure, while at the same time not toning down too much on being able to understand how tough this is really going to be. you know, one of the tougher treatments in cancer, people

think about it as a stem cell transplant, which is something i don't do, some of my colleagues do. i find that this treatment just on a very basic level with head and neck cancer, chemo, radiation is more challenging than stem cell transplant. not tougher than an owls transplant -- that's cells from another individual. i'm not making an analogy between the two treatments other than people understand how big of a deal a stem cell transplant might be and making that analogy, it's a very challenging treatment and so -- but, again, it's curative intent and so many, many, many patients can do very well with head and neck cancer treatment long term.

>> let's talk about what's changed in cancer as far as the incidence of cancer, but before we do that, i want to -- i was thinking about the difference between you and the hematologist, could you explain ha? >> yeah, so historically, the first treatments that we had in -- for any cancer was for leukemias and lymphomas, back in the '50s, '60s and '70s. those were hematologists, blood doctors that treated those diseases. and then later trickled in treatments for solid tumors, so the training track for hematology and medical oncology were melded together.

i'm certified in both hematology and oncology. >> oh, really? >> yeah. i also see non-cancerous blood disorders, as well, so -- it's something that's kind of fused together. >> impressive. >> it is impressive. >> i choose to not -- i choose to give some of the cases such as acute mã©oid leukemia and very aggressive lymphoma attention and other diseases to some other partners who focus

solely on that but i do have a broad practice. >> boy, there are some changes that have happened in that fld, though. the new chemo that's just so power flee effective. but let's look at the u.s. cancer death rate. we have a graph that we can show about what's happening. could you explain -- can you look at the cancer death rates and explain what that means? >> so, this is a long-term graph, you can see that it starts in 1930 and goes up to 2012, when it was last updated, and shows the rate of cancer per 100,000 males, so this is male-only data.

>> right, we've got to draw a big -- >> male-only data. so at least there are a few interesting things to point out on the graph itself. so you kind of -- the biggest probably eyebrow raising part of this is that lung cancer rates have increased steadily and dramatically through -- around the mid to late 1990s. >> so this is -- so look at that inches dents. >> yeah, thank you. so -- what we would see if we could put a little bit more information in here is that the

rates really started to increase around 1940, okay? and in 1940, around 1940, what happened, it was world war ii and that's when smoking rates in men dramatically increased. and so you see that the rates steadily increased until around this point when you see a peak in the mid to late 1990s, so what has happened, while in the '80s, or right around here, is when there was a strong campaign to help people to understand the risks of smoking and so the rates continued to climb over a couple of decades but have actually significantly declined over the course of the last two decades

and so i think this is credence to the idea that quitting smoking on a population level can improve lung cancer rails. again, this is male-only data so it's really interesting, we don't have the female data on here but rates for women are a little bit lower in general, but what we would see is that the peak happens about here and then it started to decline in recent years. so they peaked at a later date because women started smoking later, after world war ii, and then actually hung on to smoking habits statistically later, as well.

so i think that's one of the most interesting things on this graph. >> we had another graph that popped up just before this one that showed the kinds of cancers in women and men. take a look at that. male, female, lung bronchus in both groups about the same now. prostate percent, breast 14% in women. colon and rectum, 8%, colorectal, 8% in both groups. so what's your take-home on that? kyle, would you say anything about the incidence there? >> well, it shows you that lung cancer doesn't care if you're

male or female, you know, that both genders have taken on, you know, the risks i guess of lung cancer that are with smoking but we know that smoking is not what causes lung cancer in all cases, many patients who never smoked have lung cancers. so it shows you that it's common, and also shows us the fact that was the highest percent of deaths in the u.s., it shows that we don't do as well with lung cancer as we want to in the future. >> okay. >> one thing i would add to that is, breast cancer advocacy

is great and there's been major events in breast cancer as a result of it, higher enrollment in clinical trials than in other diseases, more rapid rates of advancement in screening, et cetera. but i think sometimes that detracts sometimes from the idea that lung cancer is the biggest killer in women above breast cancer, and i like to tell people that so that they understand how common lung cancer is, and that in men, lung cancer kills more men than prostate cancer and in women, lung cancer kills more women than breast cancer.

so an important distinction and something to understand. >> we should have more emphasis on researching in lung cancer. >> i think there has been a relative lack of that over time compared to some of the other diseases. not that lung cancer is underfunded i think is the point but it historically probably has gotten less attention, and maybe than is maybe deserved. >> there's been recent data about doing c.a.t. scan as a routine screening test for smokers. what's your take on that? do you have opinion about --

>> so the best time to get rid of cancer is when you catch it early and what's so hard about lung cancer is that, you know, we rarely catch it early if we wait for the lung cancer to declare itself. if you wait until you know you have cancer, the odds are that the cancer is more at that stage, maybe even stage four. >> coughing up blood -- >> the cancer has grown and is worse than causing the symptom. if you can catch the cancer when it's small hand in one spot, if you can take care of it right there, you can cure

it, that could be with surgery, with radiation at times, too, if someone can't have surgery. >> does a c.a.t. scan -- is it worth it? there is a radiation exposure, like 100 x-rays exposure if you -- probably less now, they've done reduction in that, but it's very expensive and then you catch it so early that you end up with removing cancers that may not even be cancers, actually. >> yeah, so when you design the screening program, you have to be -- you have to know the benefits of the screen as far as how good it is to identify cancer and how often are you

going to find things that look like cancer and aren't. so, you know, it has to be analyzed, you know, truly for a screening at the level of, you know, the nation, and, you know, when they did the study looking at screening high-risk patients, because the screening doesn't make sense if someone has a no risk for lung cancer, patients with a long-smoking history, you're more likely to find a cancer and if you can find it early and cure it, that's a great benefit. it's potential lie a great benefit from a health economic

standpoint to be able to catch them early and cure them to have patients deal with potentially more advanced or metastatic cancers. >> the criteria for screening for lung cancer are very specific based on what was done in the national lung screening study, national lung screening trial, rather, and this requires that patients have at least the equivalent of smoking a pack per day for 30 years. >> so 30-pack year -- if you smoked a half a pack for 60, that's the same as -- >> exactly. >> or two packs for 15 years, that's a 30-pack year history.

>> exactly and all those patients in that trial were either current smokers or smokers who had quit within the prior 15 years. >> and what did they find? >> well, they found that they were able to reduce lung cancer deaths which is sort of the holy grail -- >> yes, it is. >> -- of screening. if you detect a bunch of early cancers but you look at the screened group and the non-screened group and they had equal overall survival, it had not made an impact.

so it had similar rates, if you looked -- depending on what data you look at, it had similar rates of risk reduction of death due to lung cancer as risk reduction of death due to breast cancer or colorectal cancer which are commonly accepted screening -- cancers for which we have screening, and -- but the important thing is that we screen the right people. we don't screen non-smokers or minimal smokers because you would have to screen a huge number of them in order to find one cancer. in fact, i think that the study, give or take, has about

250 people were screened for every one cancer that was found. >> even in the -- >> even in the higher risk group, okay, so -- and you do find some false positives so the risk of the thing you talked about was over-diagnosis, the idea of diagnosing a cancer maybe in somebody who would not have died of that cancer, for instance. diagnosing a very early stage lung cancer in someone with very severe lung disease who may have a life expectancy of less than a year, those aren't the patients that are likely to benefit from screening.

so patients should consider talking to their doctor if they have a heavy smoking history but it's selected group of patients. >> so what is the criteria again that -- and will insurances and medicare pay for it? >> generally they're picking it up. it is now a united states preventive service task force recommendation. >> and that is if you have a 30-pack year history and... >> and a current or former smoker that quit within 15 years of -- >> so more than 15 years --

>> so an example would be a 60-year-old patient who smoked a pack a day for 35 years and quit five years ago. they quit within 15 years, never smoked the equivalent of 30-pack years, which is one pack per day for 30 years, and they're healthy, okay, those are the kind of patients that would be -- so patients should talk to their physician about that. >> and if they're 80? what if they're 80? >> that's a good question. if you look at all the different -- espstf-- united states preventive services task force, if you look at the american cancer society,

if you look at the american thoracic society, if you look at asco, the american society of clinical oncology, they all have guidelines for recommending screening for different diseases but for this particular screening test, they vary on the age range. so this -- so in the study, it was 55 to 75, or 55 -- 55 to 76 or something like that, so it's -- it's that range. are we going to screen 95-year-olds? no. should we be screening -- >> a very healthy 80-year-old.

>> maybe, maybe. if they would be able to have surgery for a lung cancer or high-energy focused radiation for a certain stage lung cancer, then, yeah -- >> and we can cure knees people with lung cancer if they're small enough or -- >> with surgery or radiation. >> you're the same with surgery almost, aren't you? >> they haven't compared them directly but if you look at the patients with surgery or radiation, they're comparable. >> let's look at the chest x-ray that we have up on the board here.

so what are we seeing here? ben? >> sure, so what i would say, you know, this patient has a mass likely here and possibly another mass here, and each some smaller once, i'll kind of erase that and maybe draw arrows instead. this is a patient, if these are cancers, this is an advanced cancer. because -- because it has spread to both lungs. now, could this area be a pneumonia? and this be an old infection and this be localized disease, cancer? yes, or maybe none of it is a cancer but you see -- what you

see which is a good thing to point out, i think, is that this is -- this is a chest x-ray and this is a single view through the chest compared to a c.a.t. scan which is actually what's used for screening which is more of, if i can say, a 3d image of the chest or at least much more comprehensive than this. >> so the c.a.t. scan would really tell you more -- >> there was many studies starting in the '80s at mayo clinic and several other institutions looking at chest x-ray for screening of lung cancer and it didn't help. so it wasn't until the nlst was published in around 2010 that we had data for screening.

>> all right. sadly, there are still cancers that will take you to the end of life. hospice care is employed to give that patient the best final days. >> a lot of times the cancer patients have started out doing active treatments, chemotherapy, radiation, those kinds of things, but when those things are no longer helping them, that's when hospice gets involved. initially, i think people are reluctant to talk about hospice because they just feel like they're giving up, but once they get acquainted with hospice and realize that we're there to help them make the most of the time that they

have, they oftentimes are telling us, i wish we would have contacted hospice sooner because they could have had more time to benefit from it. it's a hard conversation to have with patients because, you know, you're really changing their focus but i think you're also changing their hope for what they want. so in the past, when they're getting active chemotherapy, they're hoping for a cure. by the time hospice gets involved, that hope changes to something else like, i hope i can make it to my daughter's wedding or something like that. the comfort focus care is more for the patients who have

probably exhausted their curative focused care or it's not benefiting them as much as they thought it would, or the other thing is sometimes those curative focused patients are very hard on the patient so they decide they don't want to do that anymore, so then their focus becomes comfort rather than cure. i think that it's very helpful for patients and their families to have hospice involved sooner rather than later just because they can get more out of it. they can utilize the benefit longer and really get that education and extra care that hospice provides.

so we're available for the family, then, as they go through that grieving process, after the patient passes away. so that can include supportive visits, it can be phone calls, it's mailings. we do also have a grf education class that we offer to our patient families so they can get together with other people and realize that, you know, they're not alone in how they're feeling and that it's a normal process, even though it's new to them. the staff who work with our hospice patients find it very rewarding work. it's important for them to be there to help the patients

and their families but it's also very emotional. we get to know our patients at a different level than patients who are in the hospital and so our staff can go through some grieving of their own when the patients pass away. sometimes we've been seeing them for many months and they get really acquainted with them, and their families, and attached and so it's not easy work but it's very important work, and i think the staff really embrace that. >> i'm part of that hospice team as the medical director in

brookings and it's been a true joy to be part of that team. we meet once a week and lynne leads our group for the most part, and it's truly a wonderful thing. both of you involved with making a decision when it's time to start hospice? a lot of times it ends up falling in the medical oncology clinic but i think we involve -- well, generally, we want to have patients pass out of this world with comfort and grace and dignity, and so sometimes people might work together for a patient that has some pain control issues leading toward the end of life,

and we can get into the nitty-gritty of how hospice is a benefit of insurance or medicare and talk about that in a minute but what i'll say is that generally, high-end cancer treatments and radiation included, is not something that is covered as part of a hospice benefit so a lot of times we want to get things done as much as we can before a patient enrolls in hospice. and kyle and i work together a lot on those kinds of cases. >> anything to add? >> yeah, you know, that transition to -- the aggressive

care that we're going forward with chemo or radiation to the decision that we're not, we're going to make sure that we're still going to give them the care they need, it just it won't involve the most aggressive cancer treatments. it's not a -- it's not a time where the care isn't going to be provided, the relationships will still be there. those are -- those are some of the hardest discussions that we have, and then the question from a radiation standpoint at times is what can we do to potentially help them before we make that transition?

can we help with some pain they're having from a disease in their hip, that's causing bony pain, can we do that in one treatment so we're done as wick as we can so they can start getting the benefit from being on hospice. >> explain the difference between palliative care and hospice care. there is a whole trend that's happening right now in medicine and i think it's a really good trend, palliative is said a lot and then hospice -- what's the difference? >> i would say that everything that hospice is encompassed

under the larger umbrella of palliative care. so much of what i may do as a medical oncologist is palliative care from the time that i see a patient. so to palliate, essentially means to improve symptoms. so a lot of what we do is just that as part of our caring for patients, so i think -- what i tell people commonly is hospice is not a place, it's not a company, it's not an insurance benefit, it's a philosophy of how to care for patients who may not be taking treatment for whatever serious disease it is

that they have that ails them, be it heart disease, be it stroke, be it lung disease, be it cancer and i also feel, you know, that it comes back to our prior conversation about kind of doctors who may hang on to the very end, you know, trying to give treatments that may or may not be effective. i try along the way to help people to understand that at some point there may be a point when we stop treating the cancer and at that point, hospice is a great option because while we're treating the cancer, we can help to control symptoms and -- >> and add comfort therapy.

>> yep. >> i always see it as a -- let's not just call it the end of the -- although a part of what we have to say in our own minds is maybe that there's six months to go before they're likely to die but it is -- medicaid -- it is a medicare advantage, it's a financial benefit that's there for you if you qualify, and i'm telling you, patient, i'm the one who qualifies you. you're -- you qualify and maybe in six months we'll kick you off hospice because you're doing okay, i don't know for

sure, i don't know when you're going to go, but you can still qualify for this added medicare benefit. let's go for the added benefit. they'll pay more, they'll cover these things, it's worth -- now, i know that you probably don't think of it in that same way but i do as a primary care guy. any response to that? >> no, we try to think of it that way. i mean, the patients greatly benefit from not only hospice

but being on hospice for a period of time. patients who go on to hospice and only spends a couple days or weeks in the hospice don't get the full benefit, they don't get the benefit of the retinitis pigmentosa they make with the hospice team, they don't get the benefit of having the over-arching care that hospice provides not only for them but for their family. it is a great benefit that unless someone passes away unexpectedly, that everybody here would benefit at some point in their life, we just don't know when.

>> i keep thinking about -- i had two cases of mid-80s women when had an abdominal mass, surgeon opened her up, found the mass that was spread through all the walls and the omentum, debucked the actualor as much as we could, offered her hospice, six months later, kicked them off hospice, ten years later they died of heart failure. i had two cases of adenocarcinoma, no no primary and i often when i when you're an 80-year-old-plus person and you come down with cancer, that cancer is also from your cells is also 80-something years of age.

so we don't know what it's going to do. so maybe sometimes you don't do anything, you just live with it and maybe we'll take advantage of hospice and then kick you off -- i'll bring my steel-toed boots and kick you off hospice. let's talk a little bit about the alternative and complimentary medicine options. some people will say, i had a patient call me, she said, i've decided that my sister had this cancer and i encouraged her to go to mexico because they'd been to the maya, mayo said you had a 30% chance of survival, 70% chance of going -- dying within six months.

went to the cancer specialest in mexico, he said he has a better option and he gave them 60% chance. so we decided to go with mexico, pay the money. and, i don't know, they gave apricot pits or -- i don't know what they gave. what's your take on all these openings of therapy that people are desperate looking for better answers than what we can give? kyle. >> it's hard, you know, when people are desperate, they look, you know, outside the box, they look for complimentary options.

they want to try to incorporate, you know, the all tern tv medicines into the standard of care options that we're talking about in our clinics. what is hard about the complimentary alternative options out there, they're not as well understood because they haven't had as much research. are they going to be the best option for them? you know, maybe. what's hard as the doctor is saying we know if you do this, it will be better than what we have to offer and just because we don't know. and hopefully as time goes by and people actually embrace the

alternative medicines that are out there either as a treatment or as a treatment that's in conjunction, we might understand, you know, maybe how they work or the benefit they could offer, but we try to make a recommendation on data and that can be really hard when we're -- >> we have no data. >> yeah, that's really hard. >> yeah, i think there are -- for symptom control, there are multiple complimentary alternative medicine practices that do have probably some clear merit.

>> smoking mareana? >> well that, one -- probably there is a lot of data for that because the federal government doesn't allow for any federal research regarding that but, yes, there is at least plenty of anecdotal data that may help with nausea control, appetite, et cetera. i'm more thinking about things like acupuncture, i mean, this is something that, you know, i've personally some patient -- we offer acupuncture at our center and have two physicians who are trained in acupuncture who deliver it, and, you know,

i do have patients that go and they've had nausea that i could not get under control with x, y, z medication and they get acupuncture and it helps. is it for everybody? absolutely not. but there are some complimentary alternative practices that do have merit but i think patients need to be very, very selective and careful as to what they put their confidence in. >> there are renegades out there -- >> absolutely. >> -- who are looking for the dollar and there's no proof to what they're doing. how do we know?

>> yeah, any pill that actually on the bottom of the bottle says these statements have not been evaluated by the fda, the food and drug administration, you can pretty much say whatever you want to say about what that is going to do for you and it does amount to a snake oil thing. and there is snake oil out there that patients really need to be aware of and avoid because they're going to -- they can put a lot of time into this, a lot of money into it and i've seen some unfortunate cases, specifically i did have

a patient who was done in mexico when i was in fellowship training and she went into liver failure because of the sheer number of different supplements she was taking, we believe, because we had no other cause for that. so people do have to be careful about what they're doing. >> i had a patient who had breast cancer and died of the breast cancer after one year with using alternative therapies and avoided the cures that they had, so... and now, for the answer of tonight's prairie doc quiz question.

a, decline, or b, increase." the answer is, decline! what's your take on that, you guys? do you feel like that's the truth? >> i would say there have been many clear-cut developments and advances in our fld over the course of the last 20 years, and i think not the least of that is our understanding -- probably the most important thing is understanding the molecular nature of cancer. >> genetics and stuff.

>> exactly, genomics and whatever omics you want to talk about. >> we've got a minute. >> so i think that that's been a huge boon. >> so as we've gotten more to 2016, we're getting better at screening, betting better at staging the cancer and we're getting better at coming up with a treatment plan, be it a dart that's, you know, a chemotherapy that goes straight to what is making the cancer tick or a focused radiation beam or advances in surgery where they can go in and do

something minimally invasive and get the tumor out. >> in 10 second, do we have less environmental toxin to account for a decrease in cancer? >>yes or no >> i would say probably no >> i would agree no. >> no change in the toxins, it's the treatments that we have. >> yes. >> we'll be right back after this. >> all around town from stores to playgrounds, babies are on

the move and there are diseases that are on the move, too. and some of these spread easily. to best protect them from 14 diseases by the time he turns two years old, vaccinate him according to the recommended schedule so he can go on about his business and you can have peace of mind. for more reasons to vaccinate, talk to your child's doctor or go to cdc.gov/vaccine. >> he was my neighbor, a guy my age, not my patient, a man of many talents and interests, and a dear friend. he was one of those fellows who would give the shirt off his back to help you, if needed.

when he was diagnosed with cancer of the pancreas spread to liver, he, his daughters, and his friends knew how this was likely going to go. but we didn't realize how graciously he would handle his dying process until it happened. he was treated and truly helped by chemotherapy for a while, but gradually the tumor cells developed resistance to the drugs and the oncologist suggested no more chemo. he was ready to have only pain meds and hospice. in the end, per his direction, with the help of hospice and the caring people at the arlington nursing home, he

shuffled off this mortal coil comfortably, surrounded by his family and friends. fortunately, he had a compassionate and grounded primary care doctor and oncologist team who were realistic and knew when to stop intervention, loving daughters and friends to surround him with support, plenty of ready-to-heat-and-eat tater-tot-like hot-dishes, an advanced directive that said he was not to have medical intervention if pointless, and plenty of pain medicine for comfort. when i visited him two days before his death, despite an

expanding belly full of cancer, he told me he was without pain. most important, he was absolutely not fearful but courageously accepting of the dying process. in comparison, i find it tragic and too common that patients and families are overwhelmed with a fear of death. some suggest this disabling dread comes from our cultural practice of protecting children from seeing death, with the intent to make life easier on them. thus, a lifelong apprehension and running from death has become the norm.

consequently, we expect modern medicine to save us in the end, which can be a desperate, futile, and harmful hope, especially in an end-of-life situation. what's more, physicians struggle taking the time and challenge of helping people in denial face their dying process. bottom line, too many people choose to be dragged through unnecessary suffering at their end of life and, too often, doctors comply. rather, dying people should ask for and be reassured that enough comfort medicine will be provided and that it's going to be all right.

our profession has been improving in this regard, but certainly we could do better. when it's time, we should all have the opportunity for a gracious death, just like my neighbor. well, a big thank you to our guests ben and kyle. we sincerely appreciate their volunteering their time to help in the studio tonight. thank you. we are in the midst of the flu season. if you have not already done so, get your vaccine now to reduce the chance of catching the flu bug.

well, that does it for tonight. from all of us here at "on call with the prairie doc," until next time, stay healthy out there, people. >> major funding for "on call with the prairie doc" is provided in part by: >> avera is a proud sponsor of "on call" on south dakota public broadcasting. larson manufacturing is proud to support "on call television" as it continues to open doors for important medical information. and by the south dakota foundation for medical care, the medicare quality improvement organization for south dakota. and with the ongoing support of these individuals and institutions...