The failure of current cancer treatments:
The Lancet, Volume 381, Issue 9865, Page 423, 9 February 2013
Feb 4 was World Cancer Day, an opportunity to critically consider progress against cancer. Is it fair to say that the cancer medical community has failed patients living with cancer? This is a harsh statement, but according to respected oncologist, Franco Cavalli, whose Comment leads a discussion about cancer in today's Lancet: “Current strategies to control cancer are demonstrably not working.”
We publish four Comments related to World Cancer Day and a Seminar on acute myeloid leukaemia in adults. Cavalli indeed gives a blunt description of the challenge we face from cancer and he appeals to world leaders and policy makers for more effective action against cancer to incorporate the Stop Cancer Now appeal, which emphasises the UN goal of reducing premature deaths from non-communicable diseases by 25% by 2025.
In October, 2012, cancer researchers, clinicians, policy makers, industry representatives, patient advocates, and journalists from several titles, including The Lancet, met in Lugano, Switzerland, at the World Oncology Forum. Their ten-point message can be paraphrased as doing what we know how to do better in terms of prevention, treatment, and care; and learning what we do not yet know more efficiently through new models of research focused on patient benefit. Central mechanisms for achieving these changes include having a clear cancer strategy for each country, universal health coverage to deliver higher quality cancer care, and to wage war on tobacco.
World Cancer Day, 2013, set out to debunk many myths about cancer. One of those myths is that cancer is solely a health issue. The Comment by Ara Darzi and colleagues debunks that myth well by presenting some socioeconomic aspects of cancer and how these relate to sustainable development. Their message is a reminder of the increasing challenge of cancer in developing countries. Felicia Knaul, Rifat Atun, Paul Farmer, and Julio Frenk elaborate on the cancer divide in their online Comment, describing how low-income and middle-income countries have only 5% of the finance to deal with 80% of the burden of cancer.
The size of the shadow cast by cancer is enormous, as shown in The Lancet's special issue on the Global Burden of Disease Study 2010 published last December. This collaboration revealed the true and surprising extent of the rapid transitions the world is seeing—demographic, disease, disability, and risk. A key finding is the epidemic nature of non-communicable disease and its attendant risk factors. Cancer is a high priority within this broad agenda. Worldwide cancer diagnoses and deaths are increasing. 8 million people died from cancer in 2010, a 38% increase compared with 1990. Cancer diagnoses are estimated to double by 2030.
Global problems have local contexts. Therefore, it was disappointing to read research by Lindsay Forbes and colleagues that a third of people in the UK aged 50 years or older would be reluctant to present symptoms that they recognise as being suggestive of cancer to their general practitioner, because of worry about wasting doctor's time. The study of differences in cancer awareness and beliefs is part of the International Cancer Benchmarking Partnership. The Partnership seeks to improve cancer care by better understanding differences in performance between Australia, Canada, Denmark, Norway, Sweden, and the UK—countries with similar wealth, access to care, and register quality—but dissimilar outcomes. Earlyresults, published in The Lancet in 2011, showed that survival for colorectal, lung, breast, and ovarian cancer was lower in the UK, particularly in the first year after diagnosis. Examples like this one show that even among people with similar demographics, understanding of cancer, and attitudes towards cancer, perceived barriers can be as important as actual barriers to care. To promote earlier and more effective engagement of patients with cancer care will require a cultural shift by health professionals, political leaders, and citizens alike, to encourage access.
So let us return to the question we began with—has cancer medicine failed patients? In the words of cancer experts, the answer is yes. But the cancer community, together with other essential parts of the health care system (eg, primary care), recognise the deficiencies of the past. They are determined to write not a new war plan but a new future for patients at risk of—or living with—cancer. 2013 must be a watershed year for cancer.
With Western Medicine admitting failure it is essential that cancer patients include complementary therapies in their treatment plan.
Why don’t we cure more cancer patients?
By Philip A. Salem, M.D.
The recent New York Times front page story on a study criticizing care in cancer of the ovaries is timely and relevant. This study found “that only a little more than a third of patients received the best possible care.” However, it does not recognize that this problem is not confined to the treatment of ovarian cancer but relates to all kinds of cancer.
There are two major reasons for that: The bulk of cancer patients in America do not seek experts’ opinions. Even when patients come to centers of excellence, it is becoming more difficult for them to receive the best treatment. When I look back on my journey of 46 years in cancer medicine and research stretching from Memorial Sloan Kettering Cancer Center in New York to M.D. Anderson and to St. Luke’s Episcopal Hospital in the Texas Medical Center, I cannot but wonder: Why don’t we cure more patients?
The answer is simple. We have failed to implement the knowledge generated from research in the actual treatment of patients. There is a major gap between what is considered the best treatment and the treatment patients actually receive because of excessive government rules and insurance company barriers. In my opinion, the nation’s best product is not Coca Cola; it is American medicine.
Patients come to America from all over the world for advanced and innovative treatments. However, the government has often reduced medicine to a contractual, legal, even businesslike relationship between a “provider” and a “consumer.” I cannot think of anything more corrosive to the dignity of the sick than being considered “a consumer” or even more demeaning to the doctor to be considered “a provider.” This terminology is a spillover from the culture of corporate America. The relationship between a doctor and his patient is not about business; it is about life and the quality of that life. Also, it is unfortunate that the nation’s health-care debate has focused on the economics of medicine rather than the essence of medicine: how to salvage life and how to heal the sick.
While few doubt the need for the health-care system in the United States to better control the cost of care, it should not be done at the expense of the quality of care of our patients. Most of those who regulate our health-care system have never been to a medical school or have never treated a patient. As a result of government regulations, doctors are drowning in paperwork and bureaucracy, leaving them little time to tend to patients’ needs. Rather than focusing on the best patient care, doctors have to focus on protection against legal action. Instead of nurturing a strong human bond with the patient, the doctor has become apprehensive of the patient. The doctor’s ultimate role is to provide the best scientific knowledge and most humane care. This should supersede any other role.
Insurance is another obstruction to the delivery of high-quality cancer treatment and care, interfering with the decision-making process at every step: prevention, early diagnosis, diagnosis of advanced disease and treatment. There is a prevailing misconception that a patient should be treated according to “standard” protocols. The American Society of Clinical Oncology recommends that treatment should be personalized, as cancer differs significantly from one patient to another. However, doctors are reluctant to treat patients outside standard protocols and guidelines and are not free to treat patients the way they think is best, because they are forced to treat within the constraints of insurance reimbursement. For example, a PET scan that can delineate areas in the body affected by cancer — crucial information for appropriate treatment — is frequently declined by insurance.
In addition, giving appropriate dosage of chemotherapy is commonly associated with moderate to significant toxicity. Consequently, the patient must receive treatment for nausea, vomiting, fatigue and other side effects, but major components of this therapy may not be reimbursed by insurance. Another obstacle is that doctors are not usually reimbursed for time spent when the patient is not physically present in the clinic. In cancer medicine, no therapy strategy can be designed without group consultations with surgeons, radiation therapists, pathologists, diagnostic radiologists and other specialists — such consultations are often obtained while patients are absent. When this process of consultations is jeopardized, quality of care significantly deteriorates.
In addition, and most important, cancer patients require love, compassion, understanding and hope. Knowledge alone is never enough. The patient needs to see the doctor frequently, so suffering, pain and anxiety are alleviated. In cancer the journey is long and stormy. For treatment to succeed, both patient and doctor need courage, perseverance and hope. This comprehensive approach to treatment demands time no longer available to the doctor.
To deliver highest-quality medical care and to cure more cancer patients, doctors must be liberated from the excessive restrictions of insurance and overregulation by the government. The Texas Medical Center is the largest of its kind in the world and should take the lead in this direction. Cutting health-care costs is important, but it cannot reduce the quality of care.
The most important human right should be the right of the sick to receive the very best treatment. For our dignity and the dignity of the sick, we should insist that the sick deserve nothing less.
Dr. Philip Salem is in private practice at the Salem Oncology Center and served as the director of cancer research at St. Luke’s Episcopal Hospital before retiring in 2012.
"Why choose our Treatment Center?"
It is for patients who wish to collaborate actively with their doctors to do everything rational, feasible, and reasonably safe to keep their problems at bay and, if possible, reverse them.
Our objective is to use multiple strategies to achieve control and improve the patient’s quality of life. Destroying cells, per se, is no triumph if the patient’s quality of life deteriorates. Helping a patient extend their life and participate in as many normal activities as possible is more important. Of course, treating cancer is a delicate balancing act, because some effective therapies inevitably entail some measure of risk. However, maintaining negative side effects at a bare minimum is a priority. We develop truly integrative programs that incorporate conventional treatments with complementary therapies.
The intent is to use every measure, as supported by clinical data, that may be effective in slowing or reversing your problems, while making you more comfortable and boosting your spirits.
A key aspect of the therapy offered is that it is tailored to the needs of each individual patient. In this way, each patient benefits from the expertise of a diverse group of physicians that bring their own unique training and varied experience to the table. At each subsequent meeting, we look at new diagnostic information, re-evaluate the patient’s case, and makes adjustments as necessary.
Education at our Treatment Center
Another key feature of therapy is that we take pains to insure that patients have a reasonable understanding of the rationale behind their therapies. We encourage our patients to share with us their wisdom. Patients will find staff who will truly listen to them and do their best to address their concerns.
It is also significant to note that the science at our clinic is unique because there is no disconnect between the research department and the attending staff. There is a direct connection from the medical literature to the medical practices. This truly is one of the most important factors and responsible for the value of the treatments offered.