Jennifer Fisher Wilson
Wilson J.; Cancer Care: A Microcosm of the Problems Facing All of Health Care. Ann Intern Med. 2009;150:573-576. doi: 10.7326/0003-4819-150-8-200904210-00024
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Published: Ann Intern Med. 2009;150(8):573-576.
When is enough treatment really enough? This question often follows physicians in all areas of medicine and their patients throughout the course of treatment. The dilemma can be particularly difficult for oncologists for whom, giving an accurate prognosis is difficult. They tend to feel optimistic about a patient's chances of benefiting from treatment and ambivalent about dashing the hopes of patients by giving them pessimistic feedback. As a result, oncologists usually prefer to talk about the goals of care with patients rather than about whether or how likely they are to die of their disease, about how long they have to live, or the anticipated benefit from chemotherapy compared with palliative care.
Thomas E. Goffman
April 30, 2009
Who is an Oncologist?
Jennifer Fisher Wilson, scientific writer, Ann. Int. Med, did an excellent job in detailing some of the problems of modern oncology (1). I'm reminded of a young patient with breast cancer who gave me a card at the end of treatment: Surgery 26 thousand dollars Radiation Oncology 34 thousand dollars Medical Oncology 100,000 thousand dollars.
While testifying (2) before the Virginia Assembly on Certificate of Need issues, myself and others, some for one, some of us for 3 years, challenged the proposed need for new accelerators in Southeast Virginia: we felt we had enough, and, even while continuing to work effectively with US Oncology, I was being muttered as being the one calling such new out patient centers "boutique." On the national level, these new centers were strategically placed where no poor person would think of going, and those with enough money can find themselves being placed on phase IV studies, a drug company invention that is better addressed by two prior Editors-in- Chief of the New Engl J Med (3,4). A simple Pubmed search will show that Catherine DeAngelis, Editor-in-Chief, JAMA, has also long been on the trail tracking the money. At one of the days of testimony before the Virginia Assembly, a weary Assembly memory asked me: "So what you're saying is that it is all about money." That and more was the answer. The oncologists Ms. Wilson interviewed were all medical oncologists: they are bold, outspoken and give roughly ten times as much money to politicians as radiation oncologists.
Honest, sincere physicians with no conflicts of interest can be brought together as in Senator Kennedy's case. Finding an hour when a proper CME approved weekly cancer conference can be hard to assemble due to different schedules. Thus, the average patient with cancer lands on an internist's office, and from there goes a number of directions. Sheer sly work in Norfolk Virginia's largest hospital kept the line of transmission from surgeon to radiation oncologist to medical oncologist. A pathologist and a diagnostic radiologist are needed to properly fill in information at cancer conferences. Radiation saves lives, but rarely gets big funding for studies unlike medical oncology that is awash with big Pharm. In breast cancer specifically, the Danish and Canadian. reports from phase III studies of radiation after mastectomy, they have weathered the storm on post-mastectomy irradiation. But we are so entranced by US studies.
While writer Jennifer Fisher Wilson does a fine job of describing costs, relative values of life versus cost, she did sidestep the issue as to who is an oncologist; in the field we think of three kinds. As well, profit was glossed over: medical oncologists simply make more money than their surgical or radiation peers, and the key seems to buy chemotherapy in large bulk and to keep giving it until the patient is said to be in their grave. By putting patients on drug company protocols, a reward from industry of 3-4000 dollars is not unusual. Meanwhile surgical oncology has come a long way with laprosopic resections of virtually any cancer. Radiation oncology has exciting new technology, including IMRT, GIRT and protons. Radiolabeled antibodies to CD 20 offers a move toward a "magic bullet."
However, the author is right in assessing drug costs; those are the most thorny issues in the oncologies today. For a civil discussion, the Journal Of Radiation Oncology Biology physics has put out a piece (4).
1. Wilson JF. Cancer Care: A microcosm of the problems facing all health care. ANN OF INTERNAL MED 2009;150 (8), 573-576.
2. RICHMOND TIMES DISPATCH.
3. Jerome P. Kassirer. On The Take: how medicine's complicity with big business can be endanger your health.(Oxford U. Press: New York) 2005
4. Marcia Angell. The Truth About the Drug Companies: how they deceive us and what to do about it (Random House: New York) 2004.
5. Goffman TE. Hotel California.. Int J Radiat Oncol Biol Phys. 2009 Mar 1;73(3):647.
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