You see, I've worked in cancer medicine for nearly 20 years now. I'm a clinical pharmacist by training. I was in public health school in the early 1990s during the "Hillary care" debates and initially thought I might move into a career in health policy. But instead, I focused on studying clinical studies. I decided that I wanted to understand and practice evidence-based medicine, and you have to know how to evaluate and interpret clinical research results to do this.

A few days after surgery, we learned that my dad's disease was not in fact Stage I, but rather Stage IIA. I knew immediately that that meant that chemotherapy was now the next treatment of choice. Studies in the last decade have made it clear that chemotherapy extends how long you live after lung cancer surgery if you have Stage II disease. Some people appear to be cured.

"Adjuvant chemotherapy for patients with stage II, but not stage I, NSCLC is well established." American College of Chest Physicians (ACCP) Practice Guidelines, 2007.

My dad's HMO employs one oncologist in a metropolitan area of 2.8 million people, so this is who my dad had to see. She told him that he was likely to die of other causes in the next 5 years anyway, which would mean that he would be unlikely to benefit from chemotherapy. That is exactly how she put it. She told him to go home and think hard about whether he wanted quality or quantity of life. Did he want to spend his last few years dealing with the side effects of chemotherapy or enjoying time with us?

Now, you have to understand that my dad has no medical conditions that are a threat to his life in the short-term, other than this lung cancer. No uncontrolled heart disease, no diabetes, no obesity, no kidney or liver disease. You get my point. According to Social Security data, the average 77-year old man can expect to live 9 additional years. My dad's 90-year old sister helped take care of him after surgery, so you also see, longevity runs in the family.

"Age should not prevent appropriate treatment of cancer in older individuals, especially in those with adequate life-expectancy and functional reserve. The National Cancer Center Network (NCCN) has issued a series of guidelines to minimize the toxicity and promote the effectiveness of cancer treatment in older patients..." Cancer Treatment Reviews 2005;31:380-402.

I was absolutely appalled that the HMO doctor was encouraging him to skip potentially curative chemotherapy. Was it a case of ageism? We talk about this a lot in oncology. Age alone is not a reason to skip treatment. Chronologic age is not the same as physiologic age. Was it to save money for the HMO? Why waste precious dollars treating an old man who might die of something else in the interim anyway? They'd rather just keep collecting his monthly premiums for as long as possible without having to provide any actual care...

I convinced my parents to get a second opinion. I referred them to a lung cancer specialist at the number one hospital in America (at least according to US New and World Reports!). She presented his options to him exactly as a caring and intelligent professional would. My dad could try to do everything possible now to reduce the risk that this cancer will recur, because if it recurs, it is no longer curable. The recommended chemotherapy after surgery is administered every 3 weeks for 4 courses, so at worst, it's 12 weeks of treatment. You can stop at any time if the side effects are intolerable. Getting one cycle of treatment is better than getting none. Getting all four is ideal, but not always possible in "elderly" patients because some of the toxicities are cumulative. You feel worse after cycle 3 than you do after cycle 2, for example. The HMO oncologist discussed absolutely none of this with him.

"The findings of this trial [JBR.10] indicate that the negative effects of adjuvant chemotherapy [for lung cancer] on quality of life appear to be temporary, and that improvements (with a return to baseline function) are likely in most patients." Journal of Clinical Oncology 2008;26:5052-5059.

"...this analysis [elderly patients in JBR.10] shows that, despite receiving less total chemotherapy than did younger patients, elderly patients derive a similar survival benefit from adjuvant chemotherapy and with an acceptable toxicity profile." Journal of Clinical Oncology 2007;25:1553-1561.

My dad opted for the treatment course that the specialist came up with. The specialist called the HMO doctor, and the HMO agreed to administer the recommended chemotherapy to my dad, including a relatively new drug that I really thought they would deny. Finally, I felt like he was going to get appropriate care.

Ironically, my dad thinks his HMO is great. He is impressed that the HMO is in fact paying for the regimen that another physician devised. He fails to see that he would have gotten no treatment at all if the HMO had had its way. If he didn't have a daughter that understands the current standards of care in lung cancer, he would have just listened to the HMO doctor and skipped chemotherapy.

I do know that there is, of course, a chance that his lung cancer will recur despite chemotherapy. I know that he may still die of lung cancer. But ultimately, he, my mom, and I all agreed that you have to do what you can at this point because if he skipped chemotherapy and the cancer recurred, we'd spend the rest of our lives wondering "what if....?" Luckily, I won't have to wonder about this. Instead, I will wonder "what if he had listened to his HMO?"

And I will also wonder "How many other people's dads are not currently receiving appropriate care thanks to for-profit medicine and how many don't even know it?"