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Cancer or stroke?

In October, a panel of eminent doctors and researchers at the Cleveland Clinic announced a list of the top ten medical advancements that could transform healthcare in 2019. Listed in order of anticipated importance, new guidelines to treat strokes ranks third; and advances in cancer immunotherapy ranks fourth.

Probably every human that has ever existed has contemplated a few hypothetical situations, and has been certain how s/he would react, were those situations ever to transpire in reality.

Only to be proven wrong when they actually transpired. If only by a scintilla.

Six years ago, in August 2012, I completed a year long treatment for invasive breast cancer — it included surgery, chemotherapy, adjuvant therapy, and radiation therapy. A year ago, in October 2017, I experienced a mini-stroke, or a transient ischemic attack (TIA). Other than neurological deficits at the time of admission to the emergency room, detailed brain imaging showed no telltale signs of a stroke. But because strokes involve not just the brain but also the cardiovascular system (and are therefore also called cerebrovascular accidents, or CVAs), my heart was imaged and it was determined that I had a patent foramen ovale (PFO), or a hole between the right and left upper chambers of my heart, the atria. My experiences make me one of some 20 million Americans – I belong to about 6% of the population.

Cancer

Irrespective of the stage, a diagnosis of cancer becomes all-consuming both for the person diagnosed with cancer, and those who care about this person. This is hardly surprising, because of a variety of reasons, not the least of which is that despite all the advances and innovations in treating many cancers, the pall of irreversible loss, perhaps even death, looms heavily over the word “cancer”.

In fact, when aggregating all types of cancers in 2018, the American Cancer Society estimates death from cancer to be one every minute in the US (globally it is 18 times higher); when considering new diagnoses, in the US there are 3 new cancer diagnoses every minute.

Stroke

A stroke is also called a cerebrovascular accident (CVA) where part of the brain may experience a loss of blood flow, most often from a clot (ischemic stroke), and less often from a broken blood vessel in the brain (hemorrhagic stroke). There are also cryptogenic strokes — those whose cause is unidentifiable. Mini-strokes, or transient ischemic attacks (TIAs), have many of the hallmarks of a stroke, but are transient and most patients recover fully.

For stroke, the numbers are slightly less daunting when compared to cancer — the CDC estimates one death every four minutes in the US (globally it is 11 times higher); and a little over 1 new incidence of stroke every minute.

Crowded by numbers

Consider the incidence for cancer and stroke on the background of something as common as a broken bone — between 12 to 13 incidences every minute, in the US.

Cancer, stroke, and bone break incidence and death rate in the United States. (not adjusted for gender)

Although the number of broken bone cases far exceeds the number of cases of cancer or stroke, we don’t consider the breaking of bones as a major healthcare issue, because the mortality is not significant. Even if the excruciating pain from a broken bone might feel like death itself.

Treating cancers and treating strokes

The last decade has seen significant strides in early detection and treatment of many cancers, and the overall numbers of survivors has been increasing. There have also been advances in stroke treatment, albeit accompanied by less fanfare in the public arena. Although a few epidemiological studies suggest that the incidence of strokes in those individuals who have had cancer might be higher, the data are really quite limited and mostly focus on early stages of cancer diagnosis. In general, some of the standard therapies available to treat cancers can increase the possibility of clot formation, thus opening the patient to a possibility of a stroke. Indeed, one observational study suggested that 10% of stroke patients had a history of cancer.

There is a reasonable body of evidence indicating that the presence of a PFO in patients who have a TIA increases their chances of having a subsequent full-blown stroke. If a panel of biochemical tests determine that the patient has a clotting disorder one option to reduce future CVAs is to put the patient on a lifelong regimen of anti-coagulants. In the absence of a clotting disorder, physically closing the PFO is an option. However, depending on other factors surrounding a patient’s history, the neurologist in charge might recommend anticoagulants even in the absence of obvious clotting disorders; and in some instances, the combination of an anticoagulant and PFO closure might be appropriate. In other words, a systematic and careful case-by-case evaluation is made by the consulting neurologist and cardiologist to determine the best approach for the patient.

As is the case for cancer treatments, stroke treatments also are not a one-size-fits-all panacea.

After almost a year of monitoring and testing both by a cardiologist and neurologist, and after educating myself about PFO closures, I made a decision to go ahead with the closure procedure with some amount of trepidation. Trepidation, because no matter how routine a surgical procedure may be, a minuscule potential for infection always exits.

The marvels of medical technology

You’ve probably heard of Gore-Tex in the context of waterproof shoes and jackets. Wilbert L. Gore and his son, Robert W. Gore invented and patented Gore-Tex. Over the years the company they started, W. L. Gore and Associates, has diversified its product portfolio to include medical devices. Earlier this year, the FDA approved one of their devices, the GORE® CARDIOFORM Septal Occluder to close PFOs.

Image courtesy Gore Creative Technologies Worldwide

The 25 mm device is tightly packed and guided with a catheter, threading its way through the femoral vein in the groin, to its destination in the heart. The procedure is well animated in the company’s video below. Conducted under sedation and local anesthesia, a patient is in and out of the procedure room in a couple of hours.

Although I’d viewed this video before my procedure, it was only after undergoing it that it really hit home: there is no underscoring the dexterity and exquisite fine motor skills required of the physician. Consider all the steps involved, and the fact that the device must be placed into a beating heart. Starting in the groin, the catheter is threaded through the femoral vein, from where it has to enter the larger vein that feeds into the heart, the inferior vena cava. The device must then be perfectly placed between the two atria, and the egress of the catheter back out of the vein, traversing almost two feet, must also be faultless. And if all goes well, after a 4–6 hour period of observation the patient is discharged and within a couple of weeks back to previous routines.

Physicians and nurses

It is one thing to read about, watch, and be impressed by such procedures, and quite another to experience them yourself. While not ignoring the intellect, abilities, and importance of my cancer care team, those treatments while daunting, long, and painful, seemed to ride less on the motor skills of the physician. This experience also underscores the importance of supporting education and research, and also supporting reforms to reduce the inordinately long hours that medical professionals have to work. After all, would you want your physician to trace a path through your veins to your heart, working on a sleep deficit?

The differences aside, one feature common to both my cancer treatment, and PFO closure was the talent of the nurses who had to find a vein through which necessary fluids could be administered: far too many times I’ve ended up poked multiple times before a “good” vein was found. I’ve saved the names of those nurses who’ve been successful, in the hopes that I can specifically request them for future procedures — and I’m glad I’ve done that on a couple of occasions.

If we increase funding for education and research, we will continue to have highly trained scientists, physicians, and nurses doing innovative research and revolutionizing healthcare, and improving outcomes not just for cancer and stroke diagnoses, but for other diseases too. In all likelihood then, the medical advancements outlined at the Cleveland Clinic will transform lives as we look toward the horizon of the second decade of the twenty-first century.

Thanks go to Dr. Jeremy Asnes for agreeing to review the description of the PFO closure and related information, to ensure accuracy.

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