42. Man in a Van with a Scan!

Mobile Scan Van Montage

Accessed at https://www.google.co.uk/search?q=mobile+CT+scan+trailer+images&biw   on 10 February 2016

So, why am I returning to this theme again?

Well, actually I’m not, though it does provide one example where there’s a problem (with at least) though usually with only two (good or great) solutions, thus presenting decision-makers with the “horns of a dilemma”, “Hobson’s choice”, “between a rock and a hard place” etc. The dilemma here is should the NHS take an immediate cost saving – hiring from a private provider for mobile CT Scans – like the one I had carried out fairly recently, or build more facilities on their own premises? Hiring is cheaper right now so they do it – no surprise there – when government cuts are so deep and apparently never-ending.

But what about a bit of creative thinking? Why doesn’t the NHS (or even more entrepreneurial: why not an individual hospital or maybe a few hospitals) buy their own fleet of Mobile Scan Vans and then ‘rent’ them to whichever hospital or wider UK region requires them? The money may change hands but it would at least remain in the overall budget handed out to the NHS. Surely someone thought about doing this before individual hospitals started doing their own thing? Surely, or am I missing something? If I am not missing something, then maybe someone (with power and position) could at least kick off a fresh debate? Speaking of kick offs, let’s have a quick digression. So here is a new example to kick off proceedings!

Commencing on Saturday afternoon it was the start of the UK-initiated, RBS 6 Nations Rugby Championship. This annual tournament pitches each of 6 National teams against one another in a biannual alternating cycle of home and away fixtures against the same team. So each team plays 5 matches, and one year say, England will play Scotland at Murrayfield (‘away’ in other words) and next year will play them at Twickenham (at ‘home’ this time). Also, any of the teams will either have three home games and two the following year, or vice versa.

RBS 6 Nations Rugby 1

RBS 6 nations kicks off! Accessed at http://www.rbs6nations.com/en/home.php on 10 February 2016.

The tournament comprises national teams from England, Scotland, Wales, Ireland, France and the most recent European addition, Italy. The latter played damned well against, and should have beaten, France, deservedly, playing in Paris too. Once again a team was ‘robbed’ by poor refereeing decisions, ie not going to the TMO when clearly this was necessary! Further, cos it pleases me, England won and retained the Calcutta Cup (a tournament within a tournament) and both Wales and Ireland made sure they couldn’t win the other two tournaments within a tournament, the “Tri-Nations Cup”, (One UK team beating all the other three) and the “Grand Slam(One team beating all the other 5 teams).

The other kick-off happened on Sunday night/Monday (early) morning – the USA’s own version of Rugby, the 50th American Football Superbowl, though now they have pretty decent Rugby team too. This particular play-off was between the Denver Broncos and the relatively new team (brand new, to me anyway), the Carolina Panthers. I haven’t watched American Football for quite some time. In fact, John Elway, the present-day coach (or Director, General Manager or some-such) was actually playing starting quarterback for Denver Broncos some 20-odd years ago when I used to watch regularly – a new Tele-channel treat (Channel 4)! Doesn’t time fly?

Superbowl American Football 1

50th Superbowl played between Denver Broncos and Carolina Panthers. Accessed at http://www.nfl.com/videos/carolina-panthers/0ap2000000093202/Broncos-vs-Panthers-highlights on 10 February 2016.

Denver won by the way, 24 to 10, with apologies to those of you who still haven’t watched the match either on “Catch-up” or your own recording (I still absent-mindedly call this ‘taping’ a programme!). I guess, once again, this displays my age, though since I “lay it all out there” for you all in the blog anyway, this may have already taken care of that query for anyone who was curious, I suspect.

Now I must return to the primary blog entry. I rather like this cancer metaphor, so from now on ‘digressions’ will be known as secondaries (1, 2 and so on…). My intravenous Combo Chemo Cocktail day went to plan and so there’s nothing to report on the technicalities side of it. However, my visit to Ward 32 this morning prompted me to reflect on my previous visits, and that brought home the dilemma of wanting to get the best treatment (for oneself) and yet having to challenge what you are being offered in your current regime, especially when you think something that might be better is available, though you are clearly thinking and ultimately, if voiced, speaking as a non-expert. What to do, eh?

For example, today is “Chemo-day” for me, and for every other patient on my sub-wing of the ward. I can only receive treatment if my granulocytic neutrophil ‘count’ reaches a minimum threshold level, otherwise it is deemed, “too risky”. It is too risky because low levels of granulocytic neutrophils are associated with being too susceptible to potential life-threatening infections. (See my entries for Blogs 34 and 35). This happened to me a couple of ‘cycles’ ago when my granulocytic neutrophils were ‘low’. Fortunately for me my assessment day was a Friday and I had the weekend for further recovery of my “neutrophil count”. I was lucky they did recover sufficiently and I received my Combo Chemo Cocktail, on the scheduled day, on time and according to plan.

34 35 Montage

If my neutrophil count had not recovered in time what options are available? Well, the usual one offered is to postpone treatment, await neutrophil count recovery and then recommence, as soon as the neutrophils swarm back into the circulatory system and reach the magic ‘threshold value’. But what if this doesn’t happen (quickly, at least, or even before the next cycle is due?). I don’t know yet because it hasn’t happened to me. I did ask about blood or even granulocyte neutrophil transfusions, but was informed that this is not a preferred treatment since it is likely to turn off or at least reduce one’s own progenitor cell proliferation, differentiation and maturation response leading to neutrophil release into the blood stream.

So, curious biomedical scientist that I am, with some inside knowledge of my own about stem cell kinetics and haematopoietic growth factors (HGFs), I have dug around in the current online literature for some ‘answers’ or at least possible routes for a patient caught in this position.

First, there is the issue of what might be available at all, coupled to who qualifies to receive it? Then there is the issue of how much any such treatment might cost and what cost-benefit analyses are brought into the equation about who gets what? Then there might also be the issue of treatment versus severity and time course of side effects. There is also the dilemma of willingness to treat versus allowing a patient ‘s body to recover naturally. So let’s examine some of these potential dilemmas.

Let’s get the first issue out of the way quickly. A treatment for low neutrophil counts already exists and has been used in exactly the circumstances described above. I know, I have met and discussed this with another patient on our ward who knows someone, who knows someone, if you get my drift for concern about maintaining anonymity? I believe this information is true. The second part of the issue is more problematic as the case for receiving the treatment, in this case, Granulocyte Colony Stimulating Factor (G-CSF), had to be argued very strongly, though the argument clearly succeeded eventually!

So the first dilemma is should allowing neutrophil production to take place naturally take precedence over giving an exogenous source of G-CSF? This haematopoietic growth factor (HGF) is one of a family of glycoproteins that plays a major role in the proliferation, differentiation, and survival of primitive hematopoietic stem and progenitor or precursor cells, as well as release of and functional activation of some mature cells. G-CSF and other HGFs bind to specific receptors on the surface of their target cells to mediate their action. G-CSF acts upon bone marrow differentiated, unipotent precursors – differentiated from more immature or precursor multipotent and totipotent stem cells. These, predominantly, neutrophilic precursors interact with this growth factor that stimulates both proliferation and differentiation of the target precursor cells and ultimately increases the release of young, new neutrophilic granulocytes into the circulation.

Donald Metcalf. Blood. 2008 January 15;111(2):485-491.  Accessed PubMed Commons.

“Three types of action of hematopoietic cytokines. (A) Lineage restricted. (B) Action on multiple lineages; broken line shows actions only at high concentrations. (C) Sequential actions; SCF acts on stem and early erythroid progenitors, while EPO acts on more mature precursors. The notion of sequential actions was later found to be incorrect.”

HGF actions on stem cells progenitors

Hematopoietic cytokines such as G-CSF are not simply mandatory proliferative stimuli but also act on cell survival, differentiation commitment, maturation induction, and the functional stimulation of mature cells.

G-CSF montage

The importance of a hematopoietic cytokine such as G-CSF can be validated in several ways. (A) By injecting G-CSF to elevate neutrophil levels and (B) by deleting the gene, a procedure resulting in low neutrophil levels and poor neutrophil responses to challenge infections.

At least these newly released neutrophils are ‘natural’, though the “extra production” and early ‘release’ mediated by G-CSF might be barely construed as not absolutely normal, at best in my book. There would be a timescale issue, as treatment could not commence (even if G-CSF was on hand) until at least the normal starting date, with Chemo treatment then being delayed also by at least several days. I’m not sure of the protocol now used, though granulocyte life span is actually quite short, about 7-days, and so neutrophil output stimulated by G-CSF should kick in fairly soon though sometimes a sharp fall precedes the increase, normally apparent within 24 hours, peaking in a couple of days later.

Of course, if this is a known issue for a patient, say low neutrophil levels have been recorded on at least two occasions, then the treatment with G-CSF could be anticipated and commenced either before or at least on the Chemo assessment day/date, thus shortening the time required (hopefully) to raise neutrophil levels to at least the threshold value, but hopefully beyond it. Nevertheless, there may be other considerations that treatment teams take into account such as toxicity of G-CSF, though it is low but this should be discussed with the patient. The one exception to using G-CSF routinely with cancer chemotherapy to prevent neutropaenia and fever might be in the case of some lymphomas where stimulation of tumour growth may occur.

The above example highlights the more general dilemma of seeking a treatment not recommended by one’s medical team and risking upsetting them by ‘pushing’ either for it or for a “second opinion” and the “mental anxiety” that one believes might follow from such mild (or should be) confrontation with the team. It is one thing for Consultants to welcome second opinions when they initiate these because they themselves are not sure, or their immediate multi-disciplinary team (MDT) recommends it, as part of their assigned role.

It is completely different, in my view, when a patient seeks to change the MDT’s view or recommended course of action, as now an amateur rather than a professional is initiating a suggested change in direction. Power always lies with the decision makers and traditionally these are the givers rather than receivers of information, advice and medical treatments, as in these illustrations.

So, a decision to take up one’s own case is not to be taken lightly. The thought may always be there that you don’t want to upset anyone, least of all your carers or consultant, on whom you constantly depend. Everyone is human and despite guidance (the GMC document for example) and acceptance of the principles of decisions ultimately lying with the patient, we patients always have nagging doubts about whether we will continue to be treated the same as before we “made a fuss”, became a ‘difficult’ patient etc. We are also human and hear too many stories similar to the one of returned food at a restaurant coming back complete with additional, well stirred-in spittle, courtesy of an offended chef – just reacting in an unprofessional but understandable way, unfortunately.

One more illustrative dilemma will suffice to reinforce the earlier general point. How expensive is G-CSF treatment and what are the cost-benefit analyses that determine whether it is used. “Three cytokines, erythropoietin, granulocyte colony-stimulating factor, and granulocyte-macrophage colony-stimulating factor, have now been in routine clinical use to stimulate cell production and in total have been used in the management of many millions of patients.” Metcalf, D. (2008). “Haematopoietic Cytokines”. Blood. 2008 15;111(2):485-91.

Clearly the medical argument has already been won. There would seem to be no argument except cost in a budget-limited NHS hospital. I have been assured on several occasions, albeit on other issues, that cost is not the limiting and determining factor, and in spite of my offering to find funds if it was. It is unclear how to proceed when faced with these conflicting statements, so often the issue is simply dropped by the patient who inevitably feels not as informed as their medical team (undoubtedly true). And yet the patient may feel rightly that they have only one life, and their continued treatment according to the agreed regime might be their last chance – for life!

So there we have it, whilst I fully believe in challenging authority (and living with the consequences) when your actual life really does depend on the good will of your authority figures then you inevitably think twice, as “dying, not living, with the consequences” might be the outcome!

That’s all folks. Bye for now.



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