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By Elaine Schattner, MD, on August 11th, 2011 We’ve reached what may be my favorite of the proposed ways to reduce cancer care costs, published in the NEJM by Drs. Smith and Hillner. Idea Number 8 is to realign compensation to value cognitive services, rather than chemotherapy, more highly.
What the authors are saying is that we’d save money if oncologists were paid more for thinking and communicating, relative to their compensation for giving chemotherapy. They write:
Medicare data have clearly shown that some oncologists choose chemotherapy in order to maximize income for their practice.<46,47> A system in which over half the profits in oncology are from drug sales is unsustainable.
They suggest that physicians’ compensation should go up, relatively, for time spent
referring patients for participation in clinical trials; discussing orders for life-sustaining treatments; considering advance medical directives; talking about prognosis in family conferences.
I couldn’t agree more.
Take the clinical trials example. In my experience enrolling
See more Reducing Cancer Care Costs: The Value of Physicians’ Cognitive Work
By Elaine Schattner, MD, on August 7th, 2011 Today’s New York Times features an op-ed by Dr. Ezekiel Emanuel, on the oncology drug shortage. It’s a serious problem that’s had too-little attention in the press:
Of the 34 generic cancer drugs on the market, as of this month, 14 were in short supply. They include drugs that are the mainstay of treatment regimens used to cure leukemia, lymphoma and testicular cancer.
Emanuel considers that these cancer drug shortages have led to what amounts to an accidental rationing of cancer meds. Some desperate and/or influential patients (or doctors or hospitals) get their planned chemo and the rest, well, don’t.
Unfortunately, what’s behind this harmful mess is neither a dearth of ingredients nor unsolvable problems at most of the manufacturing plants. Rather, the missing chemotherapies are mainly old and inexpensive, beyond their patent protection, i.e. they’re not so profitable, and not high-priority.
Emanuel proposes that the prices of old oncology
See more Implications of the Oncology Drug Shortage
By Elaine Schattner, MD, on August 5th, 2011 Today we should move forward on the list published in the NEJM on Bending the Cost Curve in Cancer Care. We’re up to point 7 in our discussion, what’s 2nd in the authors’ proposed changes in attitudes and practice: “Both doctors and patients need to have more realistic expectations.”
This point follows closely from the previous, that doctors need to talk with patients earlier on end-of-life issues. But the central issue here is that most patients with cancer are unrealistic about their prognosis, and that oncologists do a terrible job in correcting their misperceptions:
…According to one recent study, most of the patients with lung cancer expected to live for more than 2 years even though the average length of survival is about 8 months.3
Resetting expectations will be difficult. Tools are available to help the oncologist provide truly informed consent by sharing anticipated response rates, chances of cure (always
See more On Reducing Cancer Care Costs by Resetting Expectations, and Hope
By Elaine Schattner, MD, on July 29th, 2011 We’ve reached the second half of our discussion on Bending the Cost Curve in Cancer Care. The authors of the NEJM paper, Drs. T. Smith and B. Hillner, go on to consider how doctors’ behavior influences costs in Changing Attitudes and Practice. Today’s point on the list: “Oncologists need to recognize that the costs of care are driven by what we do and what we do not do.”
In other words (theirs): “The first step is a frank acknowledgment that changes are needed.” A bit AA-ish, but fair enough -
The authors talk about needed, frank discussions between doctors and patients. They emphasize that oncologists/docs drive up costs and provide poorer care by failing to talk with patients about the possibility of death, end-of-life care, and transitions in the focus of care from curative intent to palliation.
They review published findings on the topic:
In a study at our institution
See more Reducing Cancer Care Costs: Oncologists Need to Get a Grip on Reality, and Talk about Dying
By Elaine Schattner, MD, on July 22nd, 2011 This is the sixth post on Bending the Cost Curve in Cancer Care, based on the 10 suggestions put forth by Drs. Smith and Hillner in the May 26 NEJM. We’re up to number 5 on the list for changing oncologists’ behavior: by limiting further chemotherapy to clinical trial drugs in patients who are not responding to three consecutive regimens.
They’re right.
Giving one drug or combination regimen, and then another, and another, and another, to cancer patients whose tumors resist multiple regimens is more likely to cause harm than good. Oncologists need be realistic with themselves and with their patients, in a kindly way, when treatments fail.
Options to consider, besides chemo, include palliation (which can be started at any time, including before and during chemotherapy), alternative approaches (such as hormonal or immune-based therapy, for some tumors), hospice care and participation in a clinical trial, as the authors suggest,
See more Lowering Cancer Care Costs by Limiting Chemotherapy in Patients Who Aren’t Responding
By Elaine Schattner, MD, on July 18th, 2011 
This is the fifth in a series of posts on how we might reduce the costs of cancer care, based on 10 suggestions offered in a May, 2011 NEJM sounding board. We’re up to point 4: oncologists should replace the routine use of white-cell-stimulating factors with a reduction in the chemotherapy dose in metastatic solid cancers.
In this section, the authors allude to what I think might be a cost-saving advance in oncology practice: why not make available lower doses of white blood cell (WBC) colony stimulating factors?
The issue is this: when people get high doses of chemotherapy, they’re compromised because the bone marrow doesn’t create new WBCs as it should. The risk of infection during chemo used to be so great that, in the 1980s and earlier, it was common for cancer patients to succumb to infection. With the advent of WBC stimulants in the early
See more Reducing Cancer Care Costs: Why Not Offer Neulasta in Smaller Vials?
By Elaine Schattner, MD, on July 11th, 2011 This is the fourth in a series of posts on Bending the Cost Curve in Cancer Care, by Drs. Thomas J. Smith and Bruce E. Hillner, in a recent NEJM health policy piece. The authors’ third suggestion: to limit chemotherapy to patients with good performance status, with an exception for highly responsive disease, is surely one of the most controversial.
What they’re suggesting is a simple rule: “Patients must be well enough to walk unaided into the clinic to receive chemotherapy.” There are necessary exceptions, they point out, such as cancer patients disabled by another medical condition but who otherwise can carry out daily activities with relative normalcy. (I’ll offer an example: say a 50-year woman with multiple sclerosis who is wheel-chair bound but otherwise essentially well; she would be a candidate for treatment in this scenario.) But in general the authors would hold off on chemotherapy for cancer patients
See more Reducing Costs by Holding Back on Chemotherapy for Cancer Patients Who are Frail
By Elaine Schattner, MD, on July 8th, 2011 This is the third in a series of posts on Bending the Cost Curve in Cancer Care, based on the late-May NEJM health policy piece.
Today we’ll consider the second of the authors’ suggestions: to limit second and third-line treatments to sequential monotherapies for most solid tumors. This particular suggestion, one of the few proposed with which I disagree, falls under the rubric of how oncologists’ behavior might be modified. The authors write:
A Cochrane meta-analysis showed that combination therapy had a small advantage over single agents for first-line therapy but caused more toxicity, and the review left unresolved the question of whether sequential single agents were a better choice.
…patients will live just as long but will avoid toxic effects. Second, society will benefit from cost reductions associated with less chemotherapy, fewer supportive drugs, and fewer toxicity-associated hospitalizations.
This approach is tempting, cost-wise, but may be simplistic:
See more Reducing Cancer Costs by Giving One Drug at a Time, Sequentially
By Elaine Schattner, MD, on July 7th, 2011 Yesterday’s post was not really about Avastin, but about medical journalism and how patients’ voices are handled by the media.
L. Husten, writing on a Forbes blog, cried that the press fawned, inappropriately, over patients’ words at the FDA hearing last week, and that led him to wonder why and if journalists should pay attention to what people with illness have to say, even if their words go against the prevailing medical wisdom.
There’s a fair amount of controversy on this. For sake of better discussion in the future, I think it best to break it up into 3 distinct but inter-related issues:
1. About health care journalism and patients’ voices:
A general problem I perceive (and part of why I started blogging) is how traditional medical journalists use patients’ stories to make a point. What some of my journalism professors tried to teach me, and most editors I’ve dealt
See more Patients’ Words, Unfiltered, Medical Journalism and Evidence
By Elaine Schattner, MD, on June 30th, 2011 
My cousin testified before the FDA oncology advisory board on Tuesday about her experience taking Avastin. This is a tragedy, to deny the only drug that is keeping a 51 year old woman alive.
image from p.3 of today’s NYTimes business section
You have to wonder, are the advisory panel members so rational in all their behavior and choices? Are they always so razor-like in their oncology decisions?
Unlikely.
These experts have an agenda, here: It’s to be perceived as scientists, even when their knowledge is imperfect and exceptions to the rule stand right in front of their eyes. But clinical medicine calls for flexibility, and tailoring of treatment to each case, and caring about each person, including those who fall at the tail, or in this case better end, of any Kaplan-Meier survival curve.
What would Larry Kramer do about this, I’ve been thinking:
See more No Room For Emotion or Exceptions to the Rule (on Avastin)
By Elaine Schattner, MD, on June 20th, 2011 This is the second in a series of posts on Bending the Cost Curve in Cancer Care. We should consider the proposal, published in the NEJM, gradually over the course of this summer, starting with “suggested changes in oncologists’ behavior,” #1:
1. Target surveillance testing or imaging to situations in which a benefit has been shown. This point concerns the costs of doctors’ routinely ordering CTs, MRIs and other imaging exams, besides blood tests, for patients who’ve completed a course of cancer treatment and are thought to be in remission.
The NEJM authors consider that after a cancer diagnosis many patients, understandably, seek reassurance that any recurrence will be detected early, if it happens. Doctors, for their part, may not fully appreciate the lack of benefit of detecting a liver met when it’s 2 cm rather than, say, just 1 cm in size. What’s more, physicians may have a conflict
See more Lowering Cancer Care Costs by Reducing Tests After Treatment
By Elaine Schattner, MD, on June 14th, 2011 Recently the NEJM ran a Sounding Board piece on Bending the Cost Curve in Cancer Care. The authors take on this problem:
Annual direct costs for cancer care are projected to rise — from $104 billion in 20061 to over $173 billion in 2020 and beyond.2…Medical oncologists directly or indirectly control or influence the majority of cancer care costs, including the use and choice of drugs, the types of supportive care, the frequency of imaging, and the number and extent of hospitalizations…
The article responds, in part, to Dr. Howard Brody’s 2010 proposal that each medical specialty society find five ways to reduce waste in health care. The authors, from the Divisions of Hematology-Oncology and Palliative Care at Virginia Commonwealth University in Richmond VA, offer two lists:
Suggested Changes in Oncologists’ Behavior (from the paper, verbatim — Table 1):
1. Target surveillance testing or imaging to situations in which a
See more Running 2 Lists That Might Lessen the Costs of Oncology Care
By Elaine Schattner, MD, on March 31st, 2011 An article in the March 24 NEJM called Specialization, Subspecialization, and Subsubspecialization in Internal Medicine might have some heads shaking: Isn’t there a shortage of primary care physicians? The sounding-board piece considers the recent decision of the American Board of Internal Medicine to issue certificates in two new fields: (1) hospice and palliative care and (2) advanced heart failure and plans in-the-works for official credentialing in other, relatively narrow fields like addiction and obesity.
The essay caught my attention because I do think it’s true that we need more well-trained specialists
See more In Defense of Primary Care, and of Sub-Sub-Sub-Specialists
By Elaine Schattner, MD, on March 10th, 2011 Lupus, an autoimmune disease, turned up on the front page, right side of today’s Wall Street Journal. It cropped up, also, on the first page of the New York Times business section, and elsewhere. Scientific American published a nice on-line review, just now. The reason is that yesterday the FDA approved a new, monoclonal antibody for treatment of this condition.
The drug, Benlysta (belimumab), targets a molecule called BlyS (B-lymphocyte Stimulator). The newspapers uniformly emphasize that this drug marks some sort of triumph for Human Genome Sciences, a biotech company that first reported on BlyS in the journal Science way back in 1999. BlyS triggers B cells to produce antibodies that, in patients with lupus tend to bind and destroy their own cells’ needed machinery, causing various joint, lung, liver, kidney, brain, blood vessel and other sometimes life-threatening problems. So if and when Benlysta works, it probably does so by
See more Benlysta, A New Treatment for Lupus
By Elaine Schattner, MD, on February 25th, 2011 Today a short article in the NY Times, New Kidney Transplant Policy Would Favor Younger Patients, draws my attention to a very basic problem in medical ethics: rationing.
According to the Washington Post coverage, the proposal comes from the United Network for Organ Sharing, a Richmond-based private non-profit group the federal government contracts for allocation of donated organs. From the Times piece:
Under the proposal, patients and kidneys would each be graded, and the healthiest and youngest 20 percent of patients and kidneys would be segregated into a separate pool so that the best kidneys would be given to patients with the longest life expectancies.
This all follows last week’s front-page business story on the monetary value of life.
I have to admit, I’m glad to see these stories in the media. Any reasoned discussion of policy and reform requires frank talk on health care resources which, even in the
See more Opening Up a Dialogue on the R-Word
By Elaine Schattner, MD, on February 21st, 2011 On Friday the New York Times reported that surgeons are performing far too many open breast biopsies to evaluate abnormal mammogram results. A new American Journal of Surgery article analyzed data for 172,342 outpatient breast biopsies in the state of Florida. The main finding is that between 2003 and 2008, surgeons performed open biopsies in an operating room – as opposed to less invasive, safer biopsies with needles — in 30 percent of women with abnormal breast images.
I was truly surprised by this should-be outdated statistic, which further tips the mammography math equation in favor or screening.
See more New Numbers Should Factor Into the Mammography Equation
By Elaine Schattner, MD, on February 11th, 2011 From an article in today’s New York Times on hiring discrimination against people who smoke:
“There is nothing unique about smoking,” said Lewis Maltby, president of the Workrights Institute, who has lobbied vigorously against the practice. “The number of things that we all do privately that have negative impact on our health is endless. If it’s not smoking, it’s beer. If it’s not beer, it’s cheeseburgers. And what about your sex life?”
I think he’s right, more or less, in a slippery-slope sort of way, seriously -
Lots to think about this weekend!
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By Elaine Schattner, MD, on December 23rd, 2010 Regular readers of this blog know that I’m not into rants. Complaining is rarely constructive, I know. But I spent the afternoon sorting through a 2-month stack of medical bills and correspondences related to those. Despite the fact that I consistently pay bills on time, we received threatening notices from local hospitals for payments they deemed late.
Three instances of avoidable hassle:
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See more The Grinch That Almost Stole Christmas
By Elaine Schattner, MD, on December 6th, 2010 A perspective in this week’s NEJM considers the Emerging Importance of Patient Amenities in Patient Care. The trend is that more hospitals lure patients with hotel-like amenities: room service, magnificent views, massage therapy, family rooms and more. These services sound great, and by some measures can serve an institution’s bottom line more effectively than spending funds on top-notch specialists or state-of-the-art equipment.
Thinking back on the last time I visited someone at Sloan Kettering’s inpatient unit, and I meandered into the bright lounge on the 15th floor, stocked with books, games, videos and other signs of life, I thought how good it is for patients and their families to have a non-clinical area like this. The “extra” facility is privately-funded, although it does take up a relatively small bit of valuable New York City hospital space (what might otherwise be a research lab or a group of nice offices for
See more The Cost of Room Service and Other Hospital Amenities
By Elaine Schattner, MD, on November 8th, 2010 This seems almost a perfunctory post, following last week’s front-page news about computerized tomography (CT) scans to detect lung cancer in smokers. An NIH-funded randomized trial, reported early in a Nov 4 NCI press release, included over 53,000 patients between the ages of 55 and 74 who smoke or did smoke heavily. The main finding was that annual low-dose spiral CTs, compared to annual chest x-rays, reduced mortality from lung cancer by 20 percent.
Now that I’ve had some time to reread the findings, I must admit some personal ambivalence on this, the results of which have not yet been formally published. As an oncologist, I think it’s a good thing, overall: Lung cancer is the leading cause of cancer-associated deaths in men and in women in the U.S.; it will kill over 150,000 people this year; over 80 percent of cases occur in smokers. If we could reduce mortality
See more Considering Spiral CT Scans to Detect Lung Cancer
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