Quality Cancer Care: Know It When You See It

How do you know if you or someone you love is getting the best quality care for their cancer?


 


The sad truth is that you don’t. It is difficult to impossible for most people to understand what really constitutes quality medical care.  In fact, I suspect it is also difficult for many medical professionals to measure quality cancer care.


 


The good news is that most health care professionals and the hospitals where they work want to do the best they can for their patients.  We are fortunate in that regard.


 


But despite good intentions, those of us who have seen the research which measures quality medical care know that many of those intentions fall short of the mark.


 


To address these concerns, the Cancer Quality Alliance (CQA) has written an article in the current issue of the American Cancer Society’s journal CA: A Cancer Journal for Clinicians which tries to give medical professionals and patients an understanding of what in fact constitutes high-quality cancer care.  (The Alliance is a collaboration of many different types of organizations which is committed to improving the quality of cancer care.)


 


By comparing five scenarios which outline best case and worse case scenarios, the article gives you a glimpse into the arcane world of the medical management of cancer.  In so doing, the authors show how much difference it can make when things are done right compared to what happens when they are done wrong.


 


The authors emphasize the importance of the six aims for a new health system for the 21st century, as outlined in a report from the Institute of Medicine (IOM) entitled, “Crossing The Quality Chasm: A New Health System For The 21st Century.” Those aims are that the health care system should be safe, effective, patient-centered, timely, efficient, and equitable.


 


As noted in the IOM report:


 


“Redesigning the health care delivery system to achieve these aims will require changing the structures and processes of the environment in which health professionals and organizations function, especially in 4 areas: applying evidence to health care delivery, using information technology, aligning payment policies with quality improvement, and preparing the workforce.”


 


The CQA article shows how meeting these objectives can improve the quality of care we receive for the treatment of cancer.


 


Examples include making certain that patients are treated in specialized regional cancer centers with experience in evaluating and treating uncommon cancers such as sarcomas; providing culturally sensitive, language-proficient care to allay fear and anxieties; educating patients to the sometimes unfortunate realities of their circumstances and then providing the support they and their families need; and avoiding unnecessary and potentially damaging tests and procedures which can impair the quality of life after treatment.


 


The article isn’t designed to provide information that is specific to everyone’s cancer.  Yet I suspect that a lot of people will be able to relate to these best and worse case scenarios based on their own experiences.


 


We have a lot to learn in the United States about how to deliver higher quality medical care across the spectrum of wellness and illness, not just in the treatment of cancer.


 


The data shows that we spend substantially more per person on medical care in the United States than any other developed country on this planet.  Yet our fundamental measure of outcome—the number of years lived by the typical American—falls far short of what has been achieved elsewhere.


 


The result, in my personal opinion, is that we can say we have the best technological health care in the world, but unfortunately the evidence doesn’t suggest that we deliver the best care across the board.


 


Yes, we have a lot of fancy machines, and we can do a lot to sustain life once we become ill.  But that has not translated into a longer life span.


 


I believe that medicine needs to take a first step on a multi-step journey and admit that we have a problem.  Then we need to actively address that problem, and demonstrate that we can indeed embrace quality health care as a worthy and sustainable goal.


 


I think it is important to point out that not all of the fault lies at the feet of the health care system.  There are a lot of things we do to ourselves—and don’t do for ourselves—that complicate the situation quite a bit. Medicine can’t fix everything, and it can’t deliver everything that every person would want or hope for.


 


That said, we certainly could do a much better job when it comes to improving the consistency and effectiveness of what we do for our patients. 


 


We could improve the way we communicate with our patients.  We could create systems of care that would bring the best care to the local communities where many people work and live.  We could make certain that our treatments are consistent with the latest guidelines, which in turn are based on the best evidence and expert opinion that we have.  We could support those who practice evidence-based medicine by assuring them that one more test simply isn’t needed to avoid a malpractice suit. We could make certain that the care we provide is the right care—not too little, not too much—for the situation at hand.


 


The scenarios in the CA article are a step to help all of us understand the problems we face, how they relate to the Institute of Medicine’s goals for the health care system of the 21st century, and help set expectations for patients and their families as to how they would want to be treated—and expect to be treated—if they were diagnosed with cancer.


 


As I say here often, it is good to have knowledge and hope. 


 


My hope is that we will all embrace these principles, and move forward together to make them more than just some words on a journal page.


 


We owe every patient and their family the opportunity to recognize that the care they received for their cancer—no matter the outcome—was indeed the “best scenario” for them.

5 thoughts on “Quality Cancer Care: Know It When You See It

  1. I learned from experience. If you have doubts about the care given, ask for a referral to another oncologist. It could make all the difference in the world to the care you receive. I did and I am very happy with my present oncologist. You must have complete trust and faith in the provider that treats you as your life is in his hands. In if doubt, ask for a referral. You will then be able to make an informed decision.

  2. Thanks for this post, its extremely important. I too try to raise awareness in this area of health. I was treated terribly and as a result almost died. People need to really start advocating for themselves and their loved ones. Thanks for the help

  3. There is some innate goodness of people who go into oncology. At the time when most oncologists practicing today made the decision to become oncologists, there was no chemotherapy concession. Most of them probably had a personal life experience which created a calling to do battle against the great crab. At the time people make their most important decisions in life (whether to enlist in the military, whom to marry, what career to pursue), people are at the most idealistic period of their lives.

    ——-

    A good friend told me about weekly “shrink” sessions at Lombardi Cancer Center at Georgetown. This started in the Medicine Branch of the Clinical Center of the NCI, the year before he entered his training program there. Each year, the NCI selected 10 Clinical Associates for this program; perhaps the most prestigious medical oncology training program in the world. He was very proud to have had the privilege of being one of these Clinical Associates.

    ——-

    One or two years before he started there, a Clinical Associate had committed suicide by hooking himself to a morphine drip in the on call room. From that point on, the NCI instituted a program of mandatory group sessions with a psychiatrist. The Lombardi Cancer Center was the landing zone for oncologists from the NCI who wanted to stay in the DC area. Most of the Lombardi Directors and many of its prominent oncologists came there from the NCI. So this is how that weekly shrink session at Lombardi got started. It was another NCI transplant.

    ——-

    My friend vividly recalled many of those sessions. At one of them, he remembered the comment of another Clinical Associate during one of the medical conferences in a darkened room while they were reviewing x-rays. He went on to have a great career as an academic, but at the time he spoke for all of them by suddenly blurting out “doesn’t anyone ever get better?”

    ——-

    In such an environment, it is mandatory, from a purely human standpoint, to take refuge in the smallest of successes. The shrinkage of a tumor lasting 4 weeks. The temporary relief of pain. But even with success comes bittersweet heartache. The patients are so happy when this happens. Just like a trauma victim will love forever the surgeon who fixed his/her compound fracture, the cancer patient feels genuine, heartfelt gratitude to the oncologist during periods when the cancer crab retreats.

    ——-

    But the oncologist knows it is just the eye in the hurricane. The eye passes all to quickly, and then the patient is beaten to death by the back half of the storm, which is more deadly than the front. So the oncologist only very rarely gets to share in the celebration of remissions. He/she is already worried about the day to come, when the really bad news needs to be delivered to the patient and the remission is instantly forgotten.

  4. Thanks to all for the comments.

    Gregory, your discussion is absolutely correct. In fact, the NCI experience was written up in the New England Journal. I know, because I was part of NCI when that suicide occurred, and that has remained with me my entire professional career. In fact, when I was in practice in Baltimore I started weekly therapeutic sessions in my office. We had a counselor come to the office, we shut down our work for an hour on Fridays. The discussions were important, but they also highlighted the difficulties we faced when there was so little we could do.

    Fortunately, times and treatments have changed. But one never forgets what it was like at the beginning as the specialty of medical oncology took form.

  5. Dr.
    I was diagnoised with primary liver cancer two weeks ago, Friday. I had a liver biopsy. My Oncologist was suppose to call me the following week to let me know if I was a candidate for resection, he never called, I called the after hours number and left a message, he never called. Instead another doctor (Internal Radiologist)called me early this week to let me know he talked to a liver sugeron and they agreed I am not a good candidate for surgery. They want to do a treatment called YTreium. Have you heard of it? My oncologist finally called me back yesterday and said he would call me with the final results that were sent off to Cleveland because the pathologist here cannot tell if I have an angiosacoma or a carcinoma. Does it normally take this long and should I get another opinion? I am worried that my Oncologist is not very good at getting back to his patients.

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