|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 3 | Page : 209
No miracles among friends
Medical Oncologist, The Jones Cancer Clinic, Germantown, TN 38138, USA
|Date of Web Publication||17-Aug-2014|
Medical Oncologist, The Jones Cancer Clinic, Germantown, TN 38138
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Joshi J. No miracles among friends. CHRISMED J Health Res 2014;1:209
How often does the doctor who has taken care of you during a prolonged and difficult illness also lights your funeral pyre, then takes your ashes in a basket of flowers to the Ganges?
I know of one such doctor. He cared for my sister. Years before he cared for my farther, his surgical mentor and friend. It is a very rare Hindu custom for a Brahmin daughter to light her father's funeral pyre, but that was my father's wish. Years later, the good doctor was a mentor to my son, then a novice intern and now a surgeon. All of this does matter. 
What does not matter is that my sister had acute lymphocytic leukemia with an oncogene addicted BCR/ABL fusion protein where a tyrosine kinase inhibitor (TKI) of that protein is capable of producing complete remissions.  It does not matter because there are no acute leukemia treatment facilities in my sister's hometown and the expense of such treatments is phenomenal, despite the directive from the Supreme Court of India that certain life-saving medicines (which includes imatanib, the first generation BCR/ABL TKI) be sold at a reduced price. Moreover, many basic unfulfilled needs in India, like malnutrition and malaria that claim the lives of millions still exsits. Making treatments available for adult acute leukemia to most Indians must take a place at the back of the line.
An initial bone marrow flow cytometry and molecular screening confirmed the pre-B cell phenotype and the presence of the Philadelphia chromosome - the BCR/ABL fusion protein. Imatanib and a corticosteroid were started. There were many determinations for complete blood count (CBC) and assessment of electrolytes, renal function, and uric acid levels. There were admissions for transfusions and hydration. Pre-orbital and generalized edema initially required dose modifications and unilateral blindness  then necessitated discontinuation of imatanib. Leukophoresis and radiation therapy, dasatanib and ponatanib, were not available. Dasatinib is the second-generation TKI with a 300-fold greater activity than imatinib in vitro. It is better tolerated and with steroids is associated with remissions in virtually all patients. Ponatinib, the newest third generation inhibitor, is also active in those with the TKI-refractory threonine-to-isoleucine mutation at position 315 (T315I) that confers resistance to all other approved BCR-ABL TKI's. It was granted accelerated approval in 2012 by US Food and Drug Administration. Neither of these TKI's are on that list of life-saving medicines decreed by Indian Supreme Court. I wonder how much would ponatinib cost the next Indian family whose sister could achieve a durable (>12 months) cytogenetic response, irrespective of her T315I mutation status. 
The good doctor's patient lived alone. There was no profit to be made by his many visits but interactions between doctors and patients can sometimes bring forth a physician's humanity in extraordinary light. Therein lies the miracle in this story, a lyrical tribute to a compassionate colleague and family friend. This good doctor is the kind of physician I would like to be.
| References|| |
|1.||Ogilvie H. No Miracles Among Friends. London: Max Parrish; 1959. |
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|4.||Cortes JE, Kim DW, Pinilla-Ibarz J, le Coutre P, Paquette R, Chuah C, et al. PACE Investigators. A phase 2 trial of ponatinib in philadelphia chromosome-positive leukemias. N Engl J Med 2013;369:1783-96. |