Why is cancer care failing?

by: Shirie Leng, MD

as seen on KevinMD.com

The Institute of Medicine (IOM) recently released a report on the state of cancer care in the United States.  The IOM generally knows what it’s talking about.  It’s a non-profit, non-governmental advisory group essentially.  To get on one of their advisory boards you have to be a national, if not international, expert in whatever field is being studied. According to the cancer advisory board, the state of cancer care in the United States is abysmal.

Among the problems are:

1. Doctors don’t know how to treat cancers, despite numerous guidelines for every conceivable type of cancer written by such groups as the American Cancer Society. Doctors don’t know the latest scientific research.

2. Patients often have to coordinate their own care, despite large cancer treatment centers like Dana-Farber.

3. Patients don’t get truthful information about their prognoses and don’t get good palliative care.

4. Cancer care costs too much

Yikes.  Cancer care is basically failing on all significant fronts.  Now, ironically, since one of the IOM recommendations was to improve access to training IT, you can’t get the full report without buying it from the IOM or being a member.  They might want to re-think that.  In any case, it means I can’t tell you what evidence they used to reach these conclusions.  But if you can’t believe Dr. Patricia Ganz, arguably one of the biggest experts there is, who can you believe?

Cancer care is extremely complicated, no question.  If you find a mass, is it benign or malignant?  What type of cell is growing out of control?  How fast is it growing?  What biomarkers does it have to help you decide this?  What is the genetic make-up of the cells?  Should you surgically remove it or not?  Should you take it out and then do chemo or radiation?  Neither?  Both?  Should you include a pain specialist?  A palliative specialist? Depending on the tumor, maybe you need an endocrinologist, a liver doctor, a nephrologist, a urologist, a gynecologist, or all of the above.  What does the patient want?  What is the prognosis?  How old is the patient?  How much does the patient understand?  Who will help this patient at home?  Do you admit him/her to the hospital?  If so, when and why?

That’s just the beginning.  Add to that the Affordable Care Act deciding that some breast masses should not be called “cancer” at all, prostate cancer doesn’t usually kill you, and all the questions about screening.

But isn’t that why doctors spend 8 to 10 years training? Isn’t that why they do fellowships in cancer, then further specializing into certain types of cancer, certain locations? How is it possible that care is so poor?

I’m not an oncologist.  I can tell you anecdotally from patients I have cared for in anesthesia that all the technology is not helping.  Imaging is extensive, repetitive, and exhaustive.  Biopsies are inconclusive and have to be repeated.  One technology doesn’t reach the tumor so another is tried.  Each technology requires different experts, different machines, different locations, different appointments.  The more things we can tell in the lab about tumor cells the more imaging and laboratories we need.  All this is great if it improves our understanding and treatment of cancer.  But it’s not.

Even if all the technology helped, two of the major problems the IOM pointed out are patient-centered, communication problems.  Plain and simple.  We doctors have to talk to our patients.  Until they get it, or we do.  We have to give our honest opinion without worrying about scaring people, and we have to admit when we don’t know.

Communication is the key.

Shirie Leng is an anesthesiologist who blogs at medicine for real.