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Second Opinion

Readers share their take on criticizing physicians, genetic testing and cancer’s deadly spread.

WINTER 2010
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ALMOST BLACKMAIL?

While I sympathize with physicians who encounter a “patient from hell,” I cannot fathom asking patients to waive their right to complain about their physician on online review sites, a practice Jeffrey Segal champions (“Don’t Tread on M.D.,” Fall 2009). It may not be outright blackmail, but the still-godlike status of M.D.’s makes patients reluctant to disappoint their physician by not signing such an agreement.

Sadly for Segal, empowerment of the public is the dominant paradigm of our age. Traditional boundaries and power structures are being displaced, including those within medicine. Segal represents the “lawyering” of the medical profession, which focuses on physician liability at the expense of effective or innovative treatments.

Few people select a physician based on Web sources, making Segal’s idea of forbidding patients to post to online review sites (except those he has approved) both philosophically and practically a nonstarter. His plan may even be unconstitutional as it seeks to limit speech—a limit that custom and professional courtesy have provided to physicians for hundreds of years. “Doctors bury their mistakes,” we used to say; that era is ending. This is the era of the informed, self-aware patient. Online feedback is part of this new world, in which heightened accountability of treatment providers—who will have the occasional “difficult patient”—is the norm. Segal doth protest too much.

Dag Spicer // Santa Clara, Calif.

A NEED-TO-KNOW BASIS

In her essay “Choosing Chance” (Fall 2009), Betsy Wiesendanger recounts her decision not to undergo BRCA1 or BRCA2 testing despite a family history of breast cancer, declaring that it would be “like a sword hanging over my head.” Yet she neglects to report the increased risk of ovarian cancer with a BRCA1 or BRCA2 mutation. Because ovarian cancer is often asymptomatic in its early, more curable stages, it’s typically not discovered until later stages. The standard recommendation for women with BRCA1 and BRCA2 mutations is prophylactic removal of the ovaries. I did just that after learning that I have a BRCA1 gene mutation. I also adhered to screening guidelines for women at high risk for breast cancer, and subsequently an MRI found my breast cancer at an early stage. I was treated and cured. My choices may not fit every woman who may carry BRCA gene alterations, but those women should be fully aware of what they’re deciding.

Ellen Freeman Roth // Weston, Mass.

A DEADLY SPREAD

Proto’s recent story on metastasis (“The Killing Fields,” Fall 2009) states that prostate cancer cells can live only in bone. But in fact, such cells commonly spread to lymph nodes. I am familiar with a patient who has metastatic prostate cancer in both lungs. The nodules are slowly growing (and therefore clearly content with lung tissue).

Michael A. Linshaw // Pediatrician, Massachusetts General Hospital

Joan Massagué, chair of the cancer biology and genetics program at Memorial Sloan-Kettering Cancer Center in New York City, responds: Prostate cancer metastasis occurs in bone in the vast majority of cases. Metastasis to the lungs and adrenal glands occurs in a small percentage of cases. However, as the disease reaches an advanced state, metastasis tends to be more widespread; this is true in most types of cancer.

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