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"Macho Italian" Battling Peritoneal Mesothelioma

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Paul Coppola is a 63-year-old retired inspector and supervisor in the aviation industry and a former Lance Corporal in the U.S. Marines Corps. Paul never expected his life to be a "rose garden." With the courage and pride found in the innermost being of every Marine, he has faced and beaten previous health problems having conquered both prostate cancer and heart disease.

In the early Spring of 2004, Paul noticed an unusual swelling of his abdomen. The uncomfortable swelling and weight gain continued throughout the summer. Initially, Paul took an aggressive stance strictly limiting his food intake determined to lose the excess pounds. But, in August 2004 his "starvation" diet produced a near toxic hypoglycemic event requiring him to seek medical attention at the emergency room of a nearby hospital. Tests revealed fluid in the abdomen. Paul was scheduled for a paracentesis which was performed at the Hoag Memorial Hospital in Newport Beach, California. During that procedure 10.8 liters of fluid were removed. That's nearly the equivalent of five 2-liter bottles of soda and a cup of coffee. Can you imagine how uncomfortable you would feel with that much fluid trapped inside your belly? Paul immediately dropped 30 pounds from his burly six foot frame.

The fluid removed during the paracentesis was sent to the hospital laboratory for evaluation. The cytological testing of the fluid revealed the presence of mesothelial cells but the pathologist was unable to provide a definite diagnosis. Doctors at Hoag Memorial informed Paul that the laboratory's findings were inconclusive but highly suspicious for a malignancy. It was recommended that he meet with a Hoag Memorial staff oncologist during his hospital stay. After the oncologist's physical examination of Mr. Coppola and perusal of his medical records, he urged Paul to consider a tissue biopsy.

After spending three frustrating days in the hospital, Paul was sent home with no confirmed diagnosis and no conception of what loomed ahead. After a number of sleepless nights and lengthy conversations with his wife Terrie, Paul conceded and agreed to have a tissue biopsy.

On August 20, 2004, Paul returned to Hoag Memorial where the surgeon performed an omental biopsy. A laparoscope was utilized to diligently explore the abdominal and peritoneal cavities. After the procedure, the surgeon advised Paul that his entire abdominal cavity as well as the top layer of his intestine were coated with small "bumps." One pearl-sized nodule was noted. The good news was that there did not appear to be any major organ or lymph node involvement. The bad news; the diagnosis was peritoneal mesothelioma.

Paul returned to the oncologist seeking a treatment plan. The oncologist honestly and regretfully admitted that his staff was not qualified to treat peritoneal mesotheliomas. Mr. Coppola returned to his primary care physician who suggested he try to obtain a referral to see Dr. Robert Cameron at UCLA Medical Center in Los Angeles, California. Paul's medical records were immediately forwarded to Dr. Cameron's office. Unfortunately, Dr. Cameron's expertise is in treating pleural mesotheliomas and the scheduled consultation was canceled. Dr. Cameron's office directed Paul and his wife Terrie to the Mesothelioma Applied Research Foundation (MARF).

Through MARF, Terrie was given the contact information for Dr. Brian Loggie, at Creighton University Medical Center in Nebraska and Dr. Robert Taub at Columbia University Medical School in New York. But before any appointment could be made with either physician, Paul would have to file the prior authorization provision required by his insurer. Paul would need a referral from the oncologist who had been unable to treat him.

The oncologist graciously requested the referral for Paul to see Dr. Loggie. Since there are but a handful of surgeons in the United States qualified to provide surgical treatment of peritoneal mesothelioma, the Coppola's assumed the referral to Dr. Loggie would be approved. The Coppola's contacted his office to schedule a consultation. Medical records were forwarded for his review. On September 17, 2004, the insurance company denied the request for the medical consultation with Dr. Loggie. The determination was made based upon their review of his health condition in relation to his health plan's medical necessity criteria or guidelines and in accordance with the terms and conditions of Paul's insurance plan. Specifically, Paul had requested permission to see another specialist outside of the network of providers contracted by his insurance carrier. The denial was also based on part because Paul had failed to see Dr. Cameron for his diagnosis of abdominal mesothelioma, a provider that they had previously authorized.

It was obvious that the paper pushing decision makers at the insurance company did not understand the complexity of Mr. Coppola's disease. Paul had two options. He could accept the insurance carrier's decision or file a grievance. Mr. and Mrs. Coppola decided to file an expedited grievance whereby their appeal would be resolved within 72 hours if they could prove that the standard decision process of 30 days would pose an imminent and serious threat to Paul's health.

Terrie, frustrated but determined to help her husband, contacted our office for assistance in obtaining the medical information needed to reverse the insurance carrier's decision. Daniel Dollison, Dr. Loggie's physician assistant and new patient coordinator quickly responded to our request and provided our office with a wealth of information. This research along with Dr. Loggie's curriculum vitae and description and plan of treatment, " Intraperitoneal Hyperthermic Chemotherapy for Peritoneal Carcinomatosis and Malignant Ascites" was forwarded to the insurance provider's appeals and grievance department.

During the appeal process, the insurance company requested that Mr. Coppola see another oncologist within the provider network. Mr. Coppola was scheduled to see that oncologist at Hoag Hospital on October 7. On October 1, 2004, Mr. and Mrs. Coppola were notified that the medical director of the insurance company had overturned the board's previous ruling. However, the approved authorization was for one initial consultation only and was to be done prior to October 29. All travel and lodging expenses were excluded. Any further medical treatment required preauthorization and review by the medical director and board. Paul and Terrie were elated. They had challenged the insurance company and won.

As directed, Mr. Coppola kept his scheduled appointment with the oncologist on October 7. During the consultation, Paul asked numerous questions, including the one troubling question since learning of his diagnosis. Would surgical treatment prolong his life or give him a better quality of life? The oncologist advised that surgery would probably give him a better quality of life but it may not prolong his life.

Prior to the October 7 consultation, Paul had consumed the surgical information provided by Dr. Loggie's office. Paul felt that precious time had already been wasted between the time of his diagnosis and his battle with the insurance carrier. Although he had won the first battle reversing the insurance carrier's denial, there was no guarantee that further medical treatment outside his provider network would be approved.

Paul had already survived two major surgeries. He questioned his body's strength. The fluid had returned causing a weight gain of 21 pounds. A second paracentesis performed in mid October, yielded 5.5 liters of fluid. After much contemplation and discussion with Terrie, Paul decided against surgical intervention as a treatment option. Paul chose to seek treatment with the oncologist approved by his insurance carrier.

Since making this decision Paul's emotional health has remained positive. He pulled the juicer out the cupboard and made significant changes in his diet, adding a variety of vegetables. He takes close to 20 pills a day. To keep on top of his medication, he has prepared a chart which lists each drug, the dosage and when to take it. His days are busy, filled with daily errands, visits to the Senior Center and his grandchildren's Saturday soccer games.

On November 1, 2004, Paul had his first chemotherapy treatment. He did not experience any side effects. The plan was for Paul to receive treatment at three week intervals, with continuous monitoring by his oncologist. Since November Paul has completed five treatments but as Paul explains, "it has been rough, very rough." His battle with nausea after each treatment has wrecked havoc with his blood sugar levels. When he does manage to eat, there is no taste or flavor to savor, describing each bite as if he was eating ice cubes. He complains of dizziness which limits his activity level. And, just when Paul feels he is getting his strength back it's time for another treatment.

On February 7, Paul met with his oncologist to discuss his recent CT scan and treatment plan. Paul, exhausted from the constant chaos his body endured after each chemotherapy treatment, decided to discontinue chemotherapy. Paul didn't want to know the results of his latest CT scan, and did not inquire. He told his oncologist that he needed a break, both emotionally and physically, from his treatments. His oncologist agreed that a little time away might be a good idea. Paul was taken off all his medications except what was needed to control his diabetes.

During the first part of March, Paul had another paracentesis. Paul felt that the buildup of the fluid in his abdomen, which had been kept at bay by the chemotherapy, was keeping him from being active. Since the procedure, Paul's appetite has increased along with his strength and energy. With his new "can do" attitude, Paul is making plans to finish the patio and tend to some much needed home and yard maintenance.

Terrie is afraid that Paul may try to do too much. She wishes he'd slow down and ease into his projects gradually. But she understands his determination and stubbornness. Terrie portrays Paul as "your typical macho Italian man." With that Tony Soprano constitution and attitude, we're confident Paul will continue to fight and win his battle with peritoneal mesothelioma.

*** POSTED APRIL 4, 2005 ***

Mr. Paul Coppola passed away on May 13, 2006