Monday, 14 April 2014

Waste, the oncologists say

"In first world countries, cancer treatment has adopted a culture of excess: excess in diagnosis, excess in treatment, excess in promises"

The chosen title belongs to the report that “The Lancet Oncology Commission" published and which was signed by a large group of oncologists. In the excerpt below you can see on the right, the heading of the list of authors that extends over two pages.

This is an important document critically reviewing all aspects of approaching cancer in Western countries: the cost effectiveness, the use of technology, the mad race of the new drugs, the adequacy of the research, the role of medical oncology, the surgery, the radiotherapy, the genomics, the palliative, but mostly the question that the authors pose is whether the path followed by oncology is the most appropriate, and if as a society we can afford it.

A few "pearls” selected from the document:

"Both oncologists and the related industry should be more responsible and not accept suboptimal evidence. They should fight the approach that defends small results at any cost."

"Providing futile treatments, such as chemotherapy in the last weeks of life, has not only economic consequences but also compromises the quality of life of patients, because this attitude causes the care team to not focus on palliative models which is surely much more necessary."

And this latest "pearl" leads me to the following article, written by two palliative oncologists and published in New England.

"Bending the cost curve" is a phrase that has become successful in some U.S. economic environments and when applied to health care, conveys the idea of challenge of "let's see if we can considerably turn downward the structurally augmentative trend of healthcare costs."

In the article the authors reflect upon the undeniable influence of oncologists over the costs of the proceedings, although this isn’t always well related to clinical outcomes or it is only in a meagre way despite the efforts and resources used. It’s a document that proposes something more practical than the previous recommendations and I have extracted some of the more significant ones:
  • Limit chemotherapy to patients with good performance status.
  • In patients with metastases, chemotherapy should not be forced upon them to the point of having to need white cell stimulating factors.
  • The second and third line of treatment in metastatic cancer of solid tumours should be limited to sequential monotherapy.

To finish this post, I invite you to see what the American Society of Clinical Oncology (ASCO) says when, from the "Choosing Wisely" initiative, they are asked to decide on five clinical performances that both oncologists and patients should question.

The recommendations are surprisingly strict (remember that they come from the professional world and not from assurances) and I have found it interesting to feature three of them because I find that in usual practice this is clearly not accomplished:
  • Direct anticancer treatment for patients with stage 3 or 4 must not be used with a few exceptions justified by specific evidence or clinical trials.
  • No PET, nor TAC nor bone scans in patients with newly diagnosed prostate cancer or breast cancer, at an early stage, with a low risk of metastasis, should be performed.
  • Biomarkers, PET, TAC and bone scans in asymptomatic controls monitoring patients who had been treated for breast cancer with curative intent should not be required.

Knowing that the gap between scientific evidence and clinical practice is abysmal, especially when in the case of cancer so many emotional and economical factors prevail, it’s good that the professionals, through their own means, express their view on the practices that do nothing more than serve to discredit their own profession, and that messages about the importance of assessing actual clinical outcomes, beyond personal assessments and "suboptimal" evidence are issued.

Jordi Varela

1 comment:

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