Painful Uncertainty for Cancer Patients

The patients will never know for sure. And it is an agony.

Their pharmacist, Robert Courtney, has admitted he diluted chemotherapy drugs. He gave patient after patient a third, a fifth of what they needed to fight cancer. He made more money that way.

And the patients who sat there, hour after hour as the chemo dripped into their veins? They do not know how much medication they actually got. And how much was saltwater. They will never know how much the deception might have cost them.

How many months? How many years?

“It is a haunting feeling,” Delia Chelston says. “Unthinkable.”

She is 68. She has advanced ovarian cancer. She trusted Courtney’s drugs to beat it. Now anger gnaws at the strength she knows she must conserve. But she can think of little else.

Courtney is behind bars, facing charges that could bring him 196 years in prison. Federal investigators say he told them he diluted four chemotherapy drugs repeatedly, “out of greed.”

Charge for a full dose, deliver less than half, quietly pocket hundreds of dollars in savings. He tried it out a few times last November, he told investigators. Then in the spring, he started again, watering down doses.

The FBI caught him in a sting last month. Tipped off by a suspicious oncologist, they tested 10 chemotherapy prescriptions Courtney had prepared. Not one was at full strength. The strongest contained 61% of the dose the physician had ordered. All the rest had less than 40%. The weakest, the government alleges, was virtually all saline solution.

When FBI agents came to his pharmacy on the south side of Kansas City, Courtney said he couldn’t explain why the prescriptions were not as potent as they should be.

Two days later, however, Courtney agreed to another interview with the FBI, this time with his lawyer at his side. He admitted diluting the chemotherapy drugs Gemzar, Taxol, Platinol and Paraplatin.

Courtney’s attorney has not contested any of the allegations. He has not disputed the FBI’s account of Courtney’s confession. He has openly discussed the number of patients who could have received the weakened drugs. Still, preserving his legal options, Courtney has pleaded not guilty to 20 criminal counts. His trial is set for October.

The investigation, however, is far from complete.

Eighty FBI agents are working on the probe, searching Courtney’s pharmacy for a second time on Saturday. They’re poring over records, interviewing patients, answering the nearly 2,000 calls that have flooded a hotline.

It’s as much counseling as it is investigation: They spend hours each day talking to sobbing cancer patients and their loved ones, trying to ease them through the anguish of could have, should have, if only, what if. Oncologists who used Courtney’s pharmacy are doing the same with their patients. Or to the relatives of those who have died. They have little comfort to offer.

“That may be the awful legacy of this thing. We may never be able to say to the patients: ‘You were or were not affected,’ ” says Patrick McInerney, an attorney representing several physicians who unknowingly may have dispensed the diluted drugs.

Courtney has insisted he tampered only with prescriptions for one physician. He estimates 30 to 35 patients were affected. The FBI, however, says at least 10 oncologists may have used the diluted drugs. The number of victims could well be “in the hundreds,” FBI spokesman Jeff Lanza says. And each one could have received multiple infusions of worthless chemo. “We’re not counting on [Courtney’s] statements as the final word,” Lanza said.

Indeed, agents are reviewing pharmacy records going back to 1995. They also are exploring the possibility that Courtney tampered with other medications, including noncancer drugs.

“Anything is possible at this point,” Lanza said.

Even if investigators do come up with a list of patients who received the watered-down chemo, they could not begin to approximate the toll. Would this patient have been cured if she had received the full dose? Would that one have had six more good months to live? Many of the patients who received Courtney’s chemo had late-stage, terminal cancer. Even a full dose may not have made much difference.

But who can say for sure?

“My family will always wonder what could have been,” says Kim Comfort, who lost her mother, Adelia Atwood, to ovarian cancer in February after $84,000 of chemotherapy from Courtney’s pharmacy failed.

Although she has no proof, Comfort is convinced her mother received weakened drugs. “She was cheated,” Comfort says.

Cheated, perhaps, of a fighting chance. And cheated, perhaps, of time: time to finish the dress she was sewing for her granddaughter. Time to make more of the recipes she had stashed all through her kitchen.

Her husband, Ken, knows precisely how much time they did have together: 44 years, 7 months, 10 days. He tries not to let himself think they could have had more. Adelia wouldn’t want him to be bitter, he says. So he is philosophical: “What could have been, could have been. But it wasn’t.”

His daughter, however, is fierce. “This will haunt my family,” she says, “for the rest of our lives.”

So will the unanswerable question: Why?

Courtney told investigators he did it “out of greed,” court papers state. Prosecutors hint at a more specific motive: A $600,000 tax bill coming due. But it does not appear that Courtney faced insurmountable debt. Other than the tax bill--which has been paid, his lawyer says--Courtney owed nothing except his monthly mortgage. And he is quite a wealthy man.

Court records show that he holds $8.5 million in stocks and bonds. He owns two pharmacies in the Kansas City area, with a combined value of $1.1 million. He is well off enough to donate $25,000 a year to charity.

Courtney’s assets have been frozen pending his trial. The two pharmacies are being sold.

The federal judge hearing the case has refused to release him on bond.

“Defendant’s willingness to risk the lives of several people . . . in order to add to his fortune of over $10 million clearly establishes the danger he presents to the community,” Judge Robert Larsen wrote in his detention order. Calling Courtney’s alleged crimes “startling and violent,” Larsen said: “If he is willing to commit and then admit to such conduct, I cannot imagine what else he may be capable of.”

Those close to Courtney, however, paint a different portrait of the 48-year-old pharmacist.

He is a compassionate man, they say. Devoted to his family and his church. “An ideal son,” his father, a retired minister, testified in court, between sobs.

“A month ago, I wouldn’t have even thought him capable of this,” said pharmacist Dennis Hendershot, who has known Courtney for 25 years.

Courtney coached his twin sons’ baseball team. He never missed a practice. He taught fourth-grade Sunday school, sang in the church choir, served as deacon at Northland Cathedral. And he always made time to play with his four children, stepdaughter and two grandchildren. “He always has energy for the children,” his wife, Laura, testified. “They all miss him very much.”

In addition to the criminal charges, Courtney faces an onslaught of civil suits. At least two dozen already have been filed by cancer patients and their families. More are in the works.

Several of the lawsuits also target Eli Lilly & Co., the pharmaceutical company that manufactures Gemzar. In court documents, federal investigators reported that Lilly salesman Darryl Ashley “began having concerns about the Research Medical Tower Pharmacy as early as the first part of 2000.”

Lawyers for the plaintiffs contend that Lilly should have acted immediately.

But company spokesman Jeff Newton says the issues Ashley raised at the time dealt purely with Courtney’s bookkeeping: He wanted to make sure sales figures were accurate so he could get credit toward a bonus.

Lilly investigated and found that sales figures for the Kansas City area as a whole were inaccurate due to sloppy reporting by wholesalers. The “weird and unreliable” numbers showing up in Courtney’s records were dismissed as part of the overall accounting problems in the region, Newton says.

By January 2001, Lilly had straightened out the region’s bookkeeping woes. But when Ashley checked Courtney’s records in April to determine his first-quarter bonus, he found the numbers still didn’t add up: The pharmacist was buying far less than he would have needed to fill all the prescriptions coming in.

In May, Ashley reported the discrepancy to an oncologist who used Courtney’s pharmacy regularly. She had a bag of chemotherapy tested--and found it was only one-third the strength it should have been. The FBI and the Food and Drug Administration then took over, launching the sting.

As investigators from both agencies continue the probe, the plaintiffs’ attorneys are doing some sleuthing of their own. They are reviewing medical records, trying to figure out from the side effects charted whether a given patient received a full dose of chemotherapy.

“People may think it will be difficult to prove who got the diluted treatments, but the medical records tell the story,” attorney Scott McCreight says.

Oncologists caution, however, that every patient responds differently to chemotherapy. Some survive Gemzar infusions without nausea. Some keep their hair even after Taxol. Most chemotherapies cause the white blood cell count to plummet, but some patients are unaffected. It is even possible, while rare, for a patient to exhibit inconsistent symptoms after each treatment with a given dose of a drug.

“It’s very difficult to make a concrete judgment about whether a patient actually got the full dose,” said Dr. Frank Haluska, an oncologist at Harvard University Medical School. The clinical symptoms are “a clue,” he says, “but it’s certainly not definitive.”

Delia Chelston has no use for such cautions. She looks back at her six chemotherapy treatments and is certain that Courtney diluted three of them.

Her first treatment, last October, was so strong it knocked her out: She fainted during the infusion. When it was over, she spent hours on her knees in the bathroom, vomiting. She was weak for days. She couldn’t eat. Her hair fell out. The same symptoms hit her after her second and third round.

Then, the fourth round in January: To her amazement, nothing. She felt strong. She even gained a little weight. The side effects were just gone.

“I figured my body was able to accept the drugs more,” she says. “My family called and I remember telling them how wonderful it was. I was so thrilled.”

So thrilled that when she went in for her next treatment, she joked to the nurse: “Give me double of what you gave me last time.” She felt good after that infusion too. And after her sixth and final round.

Looking back, Chelston is no longer thrilled.

She is furious.

She is frightened.