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Order in the Court
In the courtroom, truth rarely wins. Performance does. The lawyer with the best delivery, arched eyebrow, sonorous voice, and well-timed pause takes the prize. Now enter oncology, where justice wears a white coat and carries a laminated copy of the Standard of Care, 2023 Edition. Here, innovation is radioactive, curiosity is subversive, and protocol is the gospel. Your life becomes a case file. Your treatment plan? A recitation. And like any good courtroom drama, facts are optional, especially if they make things... complicated.
Exhibit A: The Estradiol Patch
You show up with evidence: real studies, international trials, lower risks, fewer side effects. The estradiol patch works. It’s effective. It’s affordable. It doesn’t melt your bones or detonate your libido. But it’s not in the sacred script. It doesn’t spawn side-effect industries. No labs, no co-pay symphonies, no cardiology referrals. Worst of all? It works too quietly. So the court responds with professional skepticism and quiet dismissal. Not because the science is bad, but because it’s not profitable, not familiar, and definitely not laminated.
Exhibit B: The Invisible Judge
You think your oncologist runs the courtroom? Think again. The real judge is The Protocol, an anonymous, ever-updating document written by a conclave of experts with biotech lanyards and shrimp-stained PowerPoints. It doesn’t know your name. It doesn’t care about your side effects. It cares about one thing: defensibility. Deviate from it, and your doctor risks audit, litigation, or worse, being labeled “noncompliant.” So your doctor sticks to the script. Not because they’re heartless, but because the system is.
Exhibit C: The System Was Not Designed for You
Let’s stop pretending this is about the best care. This is about what’s billable. The estradiol patch? It works, sure. But it doesn’t generate profit, churn, or professional turf wars. It doesn’t need five follow-ups and a cardiac clearance form in triplicate. In a rational world, this patch would be standard. In ours, it’s an orphan. It’s too logical. Too humane. So it gets quietly erased, not because it fails, but because it doesn’t serve The Machine.
Cross-Examination: I Brought My Wife
She’s a psychiatrist. Calm, informed, dangerous. She asked a logical question about alternatives. The temperature dropped five degrees. Charts were gripped like shields. You could almost hear: “Patient accompanied by highly educated threat. Monitor closely.”
Closing Argument
My client, guilty of curiosity, of bringing data, of wanting to understand, stood trial for his prostate but was sentenced for his questions. The punishment? 18 months of chemical neutering, bone loss, fatigue, and existential erosion.
Not because that was best. But because it was safe. Standard. Legally defensible. The real crime wasn’t cancer. It was a deviation. It was thinking. It was hope.
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As the son of a criminal-court judge, I used to sit in my dad's court sometimes as a teenager waiting to pick up the car when he was done. On T.V., court cases are high drama; in real life, almost every defendant pleads guilty, the defense and Crown (== U.S. District Attorney) have already agreed in advance on the sentence, and they propose it to a judge together, who usually rubber-stamps it. The whole thing takes about 5–10 minutes of courtroom time for each defendant. The big, dramatic contested cases are as rare as being struck by lightning, and even then, no judge worth their salt will allow the kinds of stunts and dramatics you see in T.V. and movies.
So while the reality might not support your "truth is a casualty" angle, it might be a good analogy for your "assembly-line medicine" angle. 🤷
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5 ReactionsI understand wanting some relief from this journey. For me personally, I don't mind taking the so called "old drugs". Yes, the side effects can wear me down more times then I want but it's keeping my condition at bay, for how long, I don't know. Yes there are new and improved drugs out there that may be better suited for me. I don't really like taking meds, never have, the side effects always get my attention. All the side effects I have don't out weight the bone pain I had. Me personally, I'm not signing up for the new and improved version of treatment until all else fails me. That's just me, I wish everyone the best on their journey. Best to all.
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6 ReactionsHans, stimulating and wry as usual and you are spot on about the patch. The more I’ve read, the more it’s made me wonder why it is not the de facto treatment for non-metastatic cases.
But I am sure some pharma marketing genius will tell R&D to add some transdermal metformin or something to the older version, call it by a nifty new name (EstraMet? MetEstra?) and sell it for the same price as Orgovyx.
Did you know that big pharma actually invented the term ‘osteopenia’ to create an illness? Its osteoporosis drug failed to increase bone density by a clinically significant amount to reverse osteoporosis but it DID increase it a tiny bit.
So marketing came up with a new ‘disease’ that their failed drug could effectively ‘treat’…you can’t make this s***t up!!😆
Phil
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6 ReactionsThe medical community live in the land of bell-shaped curves. For those few who find themselves plus/minus one minute from a peak, believing the world is flat and not knowing what they don’t know, it’s clear sailing as far as their eyes can see. Those on the slopes are continually snow plowing their way down through the six-point font laundry list of cautionary statements and side effects making up 90% of the words on the laminated SOC card. Those whose snow plowing days are over, thinking they have reached rock bottom and still lucid enough to question those who rule in the land of the bell-shaped curves are now given the opportunity to add to the six-point font laundry list of the next edition of the SOC card.
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3 ReactionsLupron the 70 year old drug should fall to the price on mandated insulin. Add metformin to it and renew the patent keeping the price at 2400. Yep, the system is broken. "Standard of care", medicine by attorney's. Sadly, whoever has the gold rules and that is big pharma. Draining your life savings to support the highest artificial drug prices in the world will make one bitter.
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4 Reactionsyou can make this shit up, provided you have a sufficiently funded marketing department, a trademark lawyer on speed dial, and a few morally flexible endocrinologists willing to ghostwrite journal articles between golf rounds.
As for EstraMet™ (tagline: “Now with bonus insulin confusion!”), I hear the Phase II trials were delayed when the patch started causing patients to hallucinate that they were actually saving money on prescriptions. Tragic side effect.
And yes, osteopenia, the gateway drug of bone diseases. It's the medical equivalent of telling someone they’re pre-bankrupt and urgently need to buy a yacht to prevent it. Pharma’s true innovation lies not in molecules, but in monetizing mild inconveniences.
Honestly, if a drug gave you seasonal depression, dry elbows, and the capacity to cry during insurance commercials, they’d just call it “Pre-Masculinity Syndrome” and suggest it runs in families. Covered by most plans, of course.
You’re right, of course, patches should be the standard. But alas, transdermal delivery doesn’t come with the same profit margin as systematically annihilating your endocrine system via a $3,000-a-month pill that also ruins your libido and your will to live.
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4 ReactionsSo have you used it? And how has it helped?
The court is the system..,
“ In the courtroom, truth rarely wins. Performance does. The lawyer with the best delivery, arched eyebrow, sonorous voice, and well-timed pause takes the prize. ”
Maybe on TV,
But based on my 35+ years as a trial attorney,
Not true in real life.
Not sure about the validity of the rest of the post…
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1 ReactionFair point. 35 years in the trenches earns respect. But perhaps our difference lies not in fact but in faith. You’ve seen justice prevail; I’ve seen theatrics rewarded. Maybe I’ve just watched too many juries nod along with a good story while the evidence weeps quietly in the corner. So yes, truth can win. But it often needs a good tailor, a lighting crew, and a flair for dramatic timing.