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Trying to steer patients (and doctors) thru the right kind of cancer treatment

Posted Jun 18 2009 1:03am

There's an article in the today's (Sunday) New York Times" Cancer Patients, Lost in a Maze of Uneven Care" that hit home to me. It lays out the difficulty for patients in finding the right doctors and the correct treatment when you have cancer.

The article highlights some consensus statements on general principles of cancer treatment by the National Comprehensive Center Network. This information is useful to get your feet wet on learning about cancer treatment and can be found here. Several specialists at super-tertiary cancer programs comment on the "shocking" lack of standardized care in many instances in how common cancers are treated. Implicit in some of these statements is the notion that you have to go to some super-duper place like Memorial Sloan-Kettering (MSK) in NYC or MD-Anderson in Houston,TX for cancer treatment.

This is an absolutely ridiculous idea to me in most instances, except for certain surgical procedures which are only done commonly by a handful of super tertiary specialists. Post-operative morbidity & mortality for some of these procedures seems to directly correlate with volume, and volume tends to accumulate in small numbers of hands. However, I work commonly with community surgeons (a number of whom trained at places like MSK) who do higher numbers of these cases then the local super sized University-based teaching hospital.

Cancers of the liver, stomach, esophagus, pancreas, brain, and advanced head and neck tumors are the ones where I think you may be better off finding one of these specialists. For breast or colon cancer it's asinine to suggest you get better surgical treatment. For chemotherapy or radiation therapy the same "cookbook" for standard treatment exists whether you're in Manhattan or Mobile,AL and you shouldn't need to travel for it. Certain investigational trials (which again aren't standard and weren't the focus of the NYT article, may require you to go to regional cancer centers)

There's a patient in the article with aggressive stage IV colon cancer with liver spread who was (appropriately I think) counseled on the futility of extra aggressive chemotherapy and suggested a palliative regimen. She's used as an example of "under treatment" when she visits a referral center in Seattle that later used more then twenty cycles of chemotherapy to likely extend her life by less then a year and subsequently went to Johns Hopkins in Baltimore for what sounds like an ill-advised radical liver resection. Ironically my little brother is actually an oncology fellow at Johns Hopkins.

Even more ironic, is that last week I authored a section about surgical treatment of liver metastasis in the colon cancer entry on Wikipedia. Small world, eh?

No mention is made of exactly how gruelling this kind of therapy is, nor is there any perspective of the costs of treatment to the system. This was over $400,000 of dollars more expensive then what was recommended by her first oncologist. In an aside to the debate over "Sicko" and government health systems, you can bet that this treatment would not be subsidized by universal health care systems in most of the rest of the world.

As part of the food-chain of the oncology system, most often for breast and skin cancer, I see this all the time. One of the frustrations of breast reconstruction is trying to read the tea leaves about what kind of chemotherapy, radiation, and mastectomy a patient will receive. Variations in any of these can dramatically affect the quality of reconstruction, which is more of a tertiary concern from an oncology perspective but is often the most important from the patients perspective.

I'm just a "dumb skin doctor" these days but in scanning the NCCN recommendations on breast cancer treatment, I found a number of statements I thought either wrong, misleading, or at least up for debate. In particular they seem to be rather eager to irradiate people (for little or no benefit) and still wedded to the idea of "lumpectomy for all". When younger women, whom generally have aggressive tumor characteristics, are made to understand that (at approaching two decades follow up) between 15-19% of people treated with lumpectomy and radiation may have local recurrence of their invasive breast cancer, the rationale and enthusiasm for breast conservation diminishes sharply.

Plastic surgeons are particularly tuned in to the problems of radiation as we inherit them for reconstruction. By and large, if you considering a lumpectomy with radiation, you do not want to ask a Plastic Surgeon's opinion of it as we disproportionately see the complications. That's a post for another day.

Rob
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