Doctors and hospitals "are doing a lot of things based on what we learned 20 or 30 years ago," says Patricia Ganz, MD, chair of the Institute of Medicine's cancer report committee and an oncologist at UCLA School of Medicine & Public Health.
An awful lot of oncology testing and treatment is futile, helter-skelter, wrong, and harmful, with costs spiraling patients into bankruptcy even as they produce outcomes the same as if no treatments were ever delivered.
That's the sense one gets from reading the Institute of Medicine's hefty new report on cancer care and talking with the authors, who seem like they're frustrated, angry, and a bit shell-shocked at all the work that will be required to change the system. A few examples:
- Because chemotherapy drugs are too often tested in healthier populations than those who get the disease, they more frequently than expected produce intolerable side-effects, prompting suffering patients to say they'd rather die than endure more toxic misery.
- Treatments are too frequently delivered by providers who aren't properly trained to perform specific surgeries, deliver chemotherapy correctly, or who don't introduce palliative care soon enough.
- Different doctors treating multiple comorbidities in the same patients never talk with each other, and aren't honest with their patients about realistic outcomes.
See Also: IOM: Cancer Care System in Crisis
What a mess. For 14 million current cancer survivors, and the 1.6 million diagnosed with new disease each year.
Doctors and hospitals "are doing a lot of things based on what we learned 20 or 30 years ago," says Patricia Ganz, MD, chair of the IOM's cancer report committee and an oncologist at UCLA School of Medicine & Public Health.
"I'll give you one example," she says. "If I'm a general surgeon, I trained and learned how to do mastectomies, but maybe I was never trained in sentinel node biopsies. Maybe I still do excisional biopsies of the breast, when a needle biopsy is the right thing to do. If so, I'm not offering standard of care."
But appropriate needle biopsies "are not what's happening in many areas around the country; a lot of women are having unnecessary procedures. Instead of having the core needle biopsy, they're getting excisions."
Here's another, she says. "We shouldn't be doing colorectal cancer screening on patients with less than a 10-year life expectancy, but we do."
And mammograms aren't supposed to be given to women over 75, because the risks outweigh the benefits. But they are.
Just this week, the American College of Surgeons and its Commission on Cancer released its five picks for the Choosing Wisely campaign, in which 50 professional medical groups list types of common care that patients and doctors should avoid.
Among their picks were the two Ganz mentioned:
- "Don't perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy,"
- "Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than ten years and no family or personal history of colorectal neoplasia.
Unnecessary testing is a huge issue for authors of the report.
"All the arguments over Obamacare could be solved fairly easily if you just got rid of the unnecessary testing," says George Sledge, MD, another author of the report, Stanford University's Chief of Oncology, and past president of the American Society of Clinical Oncology.
"Everyone agrees," he says, there's a lot of inappropriate care being delivered.
Sledge, a breast cancer specialist, gave an example of unnecessary followup care for breast cancer patients after adjuvant therapy. "Probably for the last 15 years or so, our guidelines said you should not be wasting money on CT scans, bone scans or (tumor marker) blood tests as part of routine surveillance in the absence of symptoms…because we know all those tests don't improve outcomes.
These are extremely expensive, and often produce false positives.
"We actually have level-one evidence [the most reliable kind] to suggest you shouldn't do those, yet every study of breast cancer patients in followup has said that they get overtested. And in my practice, I routinely see patients who have had that routine tumor marker test every three months for years, or bone scans, CT scans, or PET scans once a year," he says.
"We know this is a huge source of waste in our medical systems. And if we would just follow the guidelines, we would save enormous amounts of money and save our patients an enormous amount of grief."
Ganz has other examples. "Many older folks, if they had gall bladder surgery done by a surgeon, that's who they [would] go to for their colon cancer surgery years later. And they shouldn't, unless that person has enough volume and experience to take care of colon cancer with the state of the art today.
"Do they know they need to remove [a minimum of] 12 nodes? Does the pathologist assure they've examined 12 nodes? Do they know they need to give radiation and chemotherapy before removing a rectal cancer? They may or they may not."
The Commission on Cancer, a program operated by the American College of Surgeons, accredits about 1,500 hospitals where acute cancer care is delivered, but it doesn't go far enough, to outpatient settings where most cancer treatments after surgery take place, Ganz and Sledge say.
"They're not actually looking to see how often did a woman who was presenting with diffuse abdominal symptoms get operated on by a gynecologist who doesn't know anything about ovarian cancer, instead of by an oncologic gynecologist?" Ganz says.
If health systems used [better] metrics and were transparent, Ganz notes, you could actually learn how many times women at one hospital had to be re-operated on, compared to the hospital across the street. "Patients would probably want to go to the hospital that's doing it right more often."
Another example Ganz gives of wasteful care is the practice by too many doctors of prescribing the expensive and potentially toxic drug Herceptin without first confirming through genetic testing that the patient's cancer has the genetic mutation that's susceptible to that drug. Now at least one insurance company, United Healthcare, is trying to put a stop to that by demanding that doctors fax the tumor's genetic test results before it will pay for the drug, she says, and more should do likewise.
And there are doctors who prescribe fourth or fifth line chemotherapy agents to patients whose bodies have been wracked by their first treatments. "The fact is, once you've had one or two lines of treatment, you're much more debilitated, and there's no evidence to suggest these other treatments will work in these situations."
Sledge says ASCO now has its Quality Oncology Practice Initiative certification program for outpatient oncology practices, which inspects those facilities for adherence to more than hundreds of quality measures.
"In many centers, in many nursing personnel have not received appropriate training," he says.
ASCO certified practices must have someone trained in life support on the premises when chemotherapy is given, and must give competency assessments and education to new staff regarding all routes of drug administration, in order to prevent patients from experiencing drug toxicity.
But only 200 practices across the country are certified so far, and thinks payers should demand, before they reimburse clinicians, that they undergo such certification from some organization.
While he can't say that care in non-certified practices is poor, "but what's pretty obvious is that when you look at practices that have instituted (certification protocols), you see significant upticks in treatment plans, followup, and documentation of what the patient has been through. You see rapid and significant increases in safety measures."
Payers should put their feet down and not pay for unnecessary care. Why don't more of them refuse now? And certification and accreditation of cancer hospitals and practices, with solid measurements that we know exist, should be expected and publicized. These would be two great places to start.