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The Cancer Among Us

September 12, 2013

The Institute of Medicine released a report two days ago on the state of cancer care in the United States.  The IOM generally knows what it’s talking about.  It’s a non-profit, non-governmental advisory group, essentially.  To get on one of their advisory boards you have to be a national, if not international, expert in whatever field is being studied.  According to the cancer advisory board, the state of cancer care in the United States is abysmal.  http://www.iom.edu/~/media/Files/Report%20Files/2013/Quality-Cancer-Care/qualitycancercare_rb.pdf

Among the problems are:

1. Doctors don’t know how to treat cancers, despite numerous guidelines for every conceivable type of cancer written by such groups as the American Cancer Society.  Doctors don’t know the latest scientific research.

2. Patients often have to coordinate their own care, despite large cancer treatment centers like Dana-Farber.

3. Patients don’t get truthful information about their prognoses and don’t get good palliative care.

4. Cancer care costs too much

Yikes.  Cancer care is basically failing on all significant fronts.  Now, ironically, since one of the IOMs recommendations was to improve access to training IT, you can’t get the full report without buying it from the IOM or being a member.  They might want to re-think that.  In any case, it means I can’t tell you what evidence they used to reach these conclusions.  But if you can’t believe Dr. Patricia Ganz, arguably one of the biggest experts there is, who can you believe?

Cancer care is extremely complicated, no question.  If you find a mass, is it benign or malignant?  What type of cell is growing out of control?  How fast is it growing?  What biomarkers does it have to help you decide this?  What is the genetic make-up of the cells?  Should you surgically remove it or not?  Should you take it out and then do chemo or radiation?  Neither?  Both?  Should you include a pain specialist?  A palliative specialist? Depending on the tumor, maybe you need an endocrinologist, a liver doctor, a nephrologist, a urologist, a gynecologist, or all of the above.  What does the patient want?  What is the prognosis?  How old is the patient?  How much does the patient understand?  Who will help this patient at home?  Do you admit him/her to the hospital?  If so, when and why?  That’s just the beginning.  Add to that the ACA deciding that some breast masses should not be called “cancer” at all, prostate cancer doesn’t usually kill you, and all the questions about screening.

But isn’t that why doctors spend 8 – 10 years training? Isn’t that why they do fellowships in cancer, then further specializing into certain types of cancer, certain locations? How is it possible that care is so poor?

I’m not an oncologist.  I can tell you anecdotally from patients I have cared for in anesthesia that all the technology is not helping.  Imaging is extensive, repetitive, and exhaustive.  Biopsies are inconclusive and have to be repeated.  One technology doesn’t reach the tumor so another is tried.  Each technology requires different experts, different machines, different locations, different appointments.  The more things we can tell in the lab about tumor cells the more imaging and laboratories we need.  All this is great if it improves our understanding and treatment of cancer.  But it’s not.

Even if all the technology helped, two of the major problems the IOM pointed out are patient-centered, communication problems.  Plain and simple.  We doctors HAVE GOT TO TALK TO OUR PATIENTS.  Until they get it, or we do.  We have to give our honest opinion without worrying about scaring people, and we have to admit when we don’t know.  Communication.  That’s the key

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5 Comments
  1. connie permalink

    As long as doctors are pressured to see more and more patients per hour There will be less and less talking,i.e. communication. The medical industry is all about money, big money. The insurance industry is the pool that feeds the pockets of the medical industry. Obama-care is just adding billions and billions of more money to the trough. That is why some doctors who truly care are not dealing with insurance.(to say nothing of the truckloads of paperwork in insurance) and are able to offer quality care at reasonable cost.

    • Yes, more money is going into the system, money that if history repeats itself, will probably go to the wrong places. However I will just point out that the ACA never claimed to have any impact on cost. It only seeks to increase the number of people insured. Whether you think that will help or hurt, or whether it will even do this small thing, is still up for debate.

  2. Will dawson permalink

    OK, we aren’t doing well. How well are other countries doing? This is not a rhetorical, smart-ass question. My wife & I are doing the best we can. Should we be going to a different country?

    • Mr. Dawson – thanks for reading! I can’t speak about other countries directly, but some of the issues that the American medical system has make it more difficult to get good care than in say, England, with it’s universal health system. Our costs are higher, access to insurance is more difficult, and treatment is more tied to payment. On the other hand, the British system might limit care in other ways. Also, the culture of both doctors and patients is often different in other countries. Here we tend to have a “do everything no matter the cost” mentality. Maybe other places do not. I think by your very question you are showing that you are frustrated, but also that you are doing the right things. Strong self-advocacy or patient advocacy is essential. The system won’t work for you unless you push.

      • Will permalink

        ” The system won’t work for you unless you push.” So sad. Sick people are in the worst position to be assertive, both mentally and emotionally. If a patient doesn’t have an advocate, she is on her own. Sad.

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