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Patients with a Cancer Should Seek Treatment in Cancer Hospitals

Posted Mar 18 2013 12:00am

For cancer care, I strongly recommend that patients choose oncologists working in well-known cancer hospitals (see: Some Tips for Selecting a "Good" Doctor and a "Good" Hospital ). The reasons for such a choice are the following: (1) these physicians generally have specialized practices with better patient outcomes; (2) they often engage in research and teaching and thus are on the forefront of science and technology; and (3) they are generally salaried so that their livelihoods are not dependent on the selection of higher-priced therapies which may not be optimal for patients.

In multiple previous notes, I have commented on the oncology or chemotherapy concession (see: Academic Oncology and the "Chemotherapy Concession ";  The Oncology Concession Under Attack by Health Insurance Companies ). Oncologists receive a percentage of the cost of the chemotherapeutic agents they prescribe, providing a financial incentive for them to use more expensive drugs but not necessarily the most the most appropriate or best ones. A recent article in the New York Times discussed how many oncologists are not selecting the optimal treatment for women with ovarian cancer (see: Widespread Flaws Found in Ovarian Cancer Treatment ). Here is an excerpt from it:

Most women with ovarian cancer receive inadequate care and miss out on treatments that could add a year or more to their lives....The results highlight what many experts say is a neglected problem: widespread, persistent flaws in the care of women with this disease, which kills 15,000 a year in the United States. About 22,000 new cases are diagnosed annually, most of them discovered at an advanced stage and needing aggressive treatment...[A new] study found that only a little more than a third of patients received the best possible care....Ovarian cancer spreads inside the abdomen, and studies have shown that survival improves if women have surgery called debulking, to remove all visible traces of the disease. Taking out as much cancer as possible gives the drugs a better chance of killing whatever is left....Surgeons who lack expertise in ovarian cancer should refer women to specialists if the women are suspected to have the disease, but often do not....Only 37 percent [of ovarian cancer patients in a recent study] received treatment that adhered to guidelines set by the National Comprehensive Cancer Network....The guidelines for ovarian cancer specify surgical procedures and chemotherapy, depending on the stage of the disease. Surgeons who operated on 10 or more women a year for ovarian cancer, and hospitals that treated 20 or more a year, were more likely to stick to the guidelines, the study found. And their patients lived longer. Among women with advanced disease — the stage at which ovarian cancer is usually first found — 35 percent survived at least five years if their care met the guidelines, compared with 25 percent of those whose care fell short. But most of the women in the study, more than 80 percent, were treated by what the researchers called “low-volume” providers — surgeons with 10 or fewer cases a year, and hospitals with 20 or fewer.....In 2006, [another] study was published that many doctors thought would change the field forever. It compared standard intravenous chemotherapy with a regimen that pumped the drugs directly into the abdomen....Expert guidelines said [intraperitoneal infusion of chemotherapy] should be offered to every patient considered strong enough to endure it.

Although IP therapy (intraperitoneal administration of chemotherapy) has been determined to be greatly beneficial in ovarian cancer patients with spread of the neoplasm in the abdominal cavity, the approach has not been widely adopted by community oncologists. Why not you may ask? Here is the answer according to an academic oncologist; the answer was buried deeply in the article:

Part of the reason [for not using IP therapy] may involve money....With IP chemotherapy, patients also need a lot of intravenous fluids, which means unusually long treatment sessions. Oncologists are paid for treatments, not for time, so for those in private practice, long sessions can eat away at income. You don’t make a lot of money with somebody in the chair getting IV fluids. Chair time is money. I’m being a cynic here, but I think that is part of the issue....Where I live, in the Pacific Northwest, IP chemotherapy is pretty much only being done in the major medical centers, and by very few private-practice oncologists. Many say it’s too difficult, and they don’t even offer it to patients, which I think is unethical.

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