Why Can’t We Get It Right?

I recently wrote about the new Medicare program which asks oncologists to provide information about their cancer patients, and whether or not they were following accepted national guidelines in their treatment plans and programs.


Shortly afterward, an article and editorial appeared in the Journal of the American Medical Association which highlighted the problems we have as a nation in getting the right treatment to the right patient, and the length of time it takes to get “new” treatments accepted by the medical (and possibly the patient) community.


The article discusses a recommendation that was made by a National Cancer Institute consensus conference in 1990 about the treatment of patients with advanced, surgically resectable colon cancer.


Basically, based on research that had been completed prior to that conference, experts concluded that the use of a combination chemotherapy program after the surgical removal of advanced, resectable Stage III colon cancer significantly improved survival.  These studies had demonstrated a 40% decrease in the risk the colon cancer would recur in these patients at high risk, and a 33% decrease in the chance these same patients would die from their cancer.


In the cancer world, that was very exciting news for a disease that, at the time, was very difficult to treat effectively if it recurred after surgery.


One would be right to assume that doctors jumped on the news and immediately began to treat their patients with the new treatment.  The evidence suggests otherwise, and the JAMA article indicates that we could still do a much better job—based on information obtained 13 years after the initial conference.


What the authors did was look at information obtained through a program called the National Cancer Database (NCDB).  This program, which is a joint program of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society, receives information from 1430 hospitals throughout the United States.  These hospitals, which are reviewed regularly by the CoC to assure they meet agreed upon standards for the treatment of cancer, maintain tumor registries in their institutions and transmit the information to a central location for collection and analysis.


Although the information may not be obtained as quickly or as in much detail as many of us would like, the fact remains that the NCDB is the largest national source of information on what is happening with the treatment of patients with cancer in this country.  In addition, while many cancers are now diagnosed and treated outside of the hospital setting, surgery for colorectal cancer still has to be done in the hospital, which means that the information is entered into the hospital cancer database, and updates are provided periodically by the physician after the patient’s primary diagnosis and treatment.


The JAMA report is based on information obtained from over 85000 patients with colon cancer treated in 560 hospitals from 1990 through 2002.  Some of the hospitals were smaller community institutions; some were large nationally recognized cancer centers.  What they all provided was information that can give us a sense of how patients fare in the community setting, as opposed to clinical trials which are much more selective and controlled in terms of who gets treated and how they get treated. 


In other words, the information in this report based on the NCDB data is more “real world” and helps us to understand what is actually going on with medical care as opposed to what may be seen in a research program.


So what were some of the findings? 


First, some good news: the use of adjuvant chemotherapy in patients with advanced resectable colon cancer increased from 39% in 1991 to 64% in 2002.  Five year survival in these patients at high risk of recurrence increased 16% compared to surgery alone, supporting the initial research findings that adjuvant treatment (preventive therapy given after primary surgery) really does work as predicted from the studies done in the 1980s.  And, adjuvant therapy worked just as well in older folks(80 years of age and over) as it did in younger people (the average patient who gets colon cancer in this country is in their late 60s, which means that a number of people are much older when they are diagnosed).


But there was some not-so-good news as well.  Although blacks were treated less frequently in the beginning of the study, they had the same treatment rates at the end of the study.  Despite that, they had less benefit from the treatment for uncertain reasons.  Women were treated less frequently than men, and as mentioned the elderly—who apparently have an excellent response to the treatment—received it less frequently for a number of reasons, including physician bias that the risk of the treatment was greater than the benefit.


But in one area in particular, the results of the study were unsettling:  despite a long history of knowing that this treatment works, only about 2 out of every 3 patients who should have received the adjuvant therapy actually got it.  That means about 28,000 people did not receive a treatment with a proven benefit of decreasing their chances of the cancer returning, and did not have the opportunity to improve the odds that their life could be saved.


There may well be good and valid reasons why these patients didn’t get the adjuvant therapy.  Perhaps they were truly infirm and in poor health.  Perhaps they didn’t want to go through the chemotherapy because they couldn’t get to the doctor or didn’t want to deal with the side effects.  But one reason that should not be on the list is because their doctor didn’t talk to them about it.


The same data base that provided the information for this study also can tell us which hospitals have a high rate of appropriate adjuvant therapy for colon cancer, and which ones don’t.  Maybe it’s time patients asked their doctors what their hospital’s rate is for complying with this recommendation.  Maybe hospitals should voluntarily post their information publicly for all to see.  Maybe we should ask Medicare to ask the doctors specifically when they care for patients with advanced colon cancer whether or not they gave the patient the right treatment, and if they didn’t give the treatment, what valid reason they have for not offering it to their patient.


As a profession, we can no longer hide behind the skirt of the concept that every doctor does everything right.  Study after study shows this just isn’t the case.  And here we have evidence that despite many, many years of knowledge we aren’t anywhere near where we should be in giving a potentially life saving treatment—even to patients who are over 80 years old.


I respect my physician colleagues, and I support them actively in a number of ways including providing extensively of my time and expertise.  But I can no longer accept that we can’t get the right treatment to the right patient at the right time on a consistent basis.  It is particularly disheartening when talking about a treatment that over time has proven it has life saving potential.


As a profession, we have an obligation to commit to systems that verify the quality of our care.  We have an obligation that every patient who can and should receive this treatment is able to receive it.  Nothing less is acceptable, and what this study highlights is that we can’t wait another 20 years to make it better.

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