By Henry Ehrlich
A few years ago we covered avidly the treatment for severe asthma known as Bronchial Thermoplasty — “BT” — in the wake of its being approved by the FDA. Briefly, a specialist inserts a device into the lungs and zapping with heat airway smooth muscles that have become permanently thickened by years of asthmatic bronchoconstriction. NYU pulmologist Dr. Frank Adams (of SiriusXM Doctor Radio fame) gave us a detailed description of the procedure here.
Bronchial thermoplasty is prescribed under rigorous standards. Dr. Ehrlich covered a talk by Dr. Arthur Sung at the New York Allergy and Asthma Society who told the audience he only accepts 20% of patients who are referred to him. “The rest are either COPD, whose lung damage can’t be reversed by heat any more than it can by medication, or asthmatics who are clearly not compliant with their medication regimens. BT is a last resort, not an easy way out. For now, BT is only being offered at certain medical centers around the country. I worry a bit that as it becomes more widely adopted, the lure of an $18,000 payday will become irresistible to other, less-careful practitioners.”
But the most important perspective was that of the patient. We got an eloquent, moving account from Tony Cook, who was the first patient to undergo BT in a non-research setting and who later testified before an advisory committee of the FDA. Among the highlights (or lowlights) of his account:
My daily medical regime was daily Advair, daily albuterol. Also, I kept oxygen in my house, which I used about once a week, mostly during the spring and summer….In 1990 I had to be honorably medically discharged from the United States Air Force. Don’t ask me how an asthmatic could squeak past the recruitment process since I understand asthma is an automatic disqualifier for military service, and they were in full possession of my medical history. Regardless, a severe asthma attack led to a grand mal, hypoxic seizure, which was followed by a return to civilian life.
We decided to revisit the subject of BT when the Annals of Allergy Asthma & Immunology published “Bronchial Thermoplasty: a review of the evidence” by Chelle Pope Wilhelm, MD, and Bradley E. Chipps, MD.
Among their findings—80% of the oft-cited figure of $56 billion in costs related to asthma come from emergency department (ED) visits and hospitalizations.
But it was really the patient data for five-year post-treatment that are important, and some of them are pretty dramatic:
In a study of 162 of the original 190 patients, “The proportion of the original 190 patients experiencing a severe exacerbation in years 1 through 5 remained at 21% to 30% compared to 51.6% 1 year before the procedure…severe exacerbation was decreased 48% at 5 years…[BT patients] had 78% fewer ED visits…there were no incidences of pneumothorax, intubation with mechanical ventilation, cardiac arrhythmias, or death in the 5 years after BT.” And so on.
However, the real eye-opener was a metric called “quality-adjusted life years.” This incorporates the “quantity and quality of life.” The baseline for standard of care included physician office visit, ED visits, hospitalizations, and medication costs. They also included data on standard treatment with omalizumab (Xolair). For BT, with its $18,000 cost for three-treatments, the cost per quality-adjusted life year was $5,495. For Xolair treatment, which entails monthly injections forever, the cost was $278,200!
A dramatic difference. The numbers speak for themselves. But what was missing from the article was the human voice, so for that I reached out again to Tony Cook, whom we last heard from in these pages in 2013, although we do correspond a bit and follow each other on Twitter.
AAC: Tony, thanks for taking time with our readers. Please start by telling us all your activities that you feel have been enabled by your bronchial thermoplasty (include athletics, physical trainer job, and budding acting career).
Tony Cook: First let me thank you Henry for all your wonderful books and columns on asthma, and all you have done for asthmatics. I am happy that I had the procedure and tell people it was like winning the lottery. Since the BT surgery, I have rarely missed work and have been racing competitively. I also spent a year as a University professor at night and on the weekends, in addition to my full time job. Every year I have gotten faster in the 5k and the mile run, currently running a 6-7 minute mile. In addition, I enjoy being able to talk to people after the races about what the procedure has done for me. I am always surprised how many other racers have friends/and/or relatives who are asthmatics and have never heard of BT.
AAC: When you wrote to me that you had auditioned for the Netflix series “House
of Cards” you said it was at the urging of your friends. Do you have more friends now than you did when you were on oxygen and so forth? I know that severe asthma can be depressing and anxiety provoking and that the treatments have psychological effects of their own. How do your friends talk about your “transformation” if that’s an appropriate word?
Tony Cook: Last year I auditioned and they accepted me on the show. It was a lot of fun and a great experience. My friends see me and say, “Who is this guy?” They were used to me always being sick, nervous about committing to things and not very active.
AAC: Could you give us a timetable for a typical day, before and after?
Tony Cook: Before BT my typical day consisted of waking up from a night of wheezing and coughing and reaching for an inhaler. I was too weak from the asthma to exercise and missed numerous days of work. A year and a half before the surgery, I was unable to work and had to use an oxygen tank from time to time.
Since BT. I get up at 4:00 a.m. and go for a run in the woods, usually running about 3 miles. Then I put in an 8 hour plus day as an IT Manager. I spend the weekends with my girlfriend and when possible enter a 5 K race.
AAC: Finally, any signs of regression? What do your doctors say about your long-term prognosis?
Tony Cook: There have been no signs of regression whatsoever. As the first BT procedure recipient, there are no definitive answers, but 7 years later it certainly appears to be extremely successful. I am so grateful to my doctors at Virginia Hospital Center and Boston Scientific for this procedure. My goal is to “Pay it Forward.” Last year I donated money to Virginia Hospital Center to help provide BT for asthmatics. I also worked with Virginia Hospital Center on a fundraising brochure about my life with asthma. I was recently a speaker for Boston Scientific at an asthma awareness conference in North Carolina. I had a sponsor who was paying for my races, but currently I am without sponsorship. I would love to work with a company, not only to sponsor my races, but as a speaker to promote awareness about asthma and the latest procedures available.
AAC: Thanks again, Tony.
PS: We also checked in with Dr. Frank Adams about BT from the pulmonologist point of view. He wrote that at the American Thoracic Society, “the thinking expressed at one severe asthma session was that we should take a hard look at this procedure since the initial data did not follow the sham group who had bronchoscopy but did not get the thermoplastic procedure. There was a call for a registry of all patients who had the procedure. I have recommended the procedure to 2 patients with severe asthma who were uncontrolled on maximal therapy but both have yet to have the procedure (lack of coverage, patient concern). Based on what I know I would still recommend the procedure for those patients who have failed maximal therapy.”
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