Dr. Len's Cancer Blog

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Dr. Len's Cancer Blog

The American Cancer Society

Report to the Nation: Room for Improvement

by Dr. Len October 04, 2005

Every year my colleagues at the American Cancer Society along with the National Cancer Institute, the Centers for Disease Control and Prevention and the North American Association of Center Cancer Registries publish the “Annual Report to the Nation on the Status of Cancer.”  This year’s report, covering the years 1975-2002, discusses trends in cancer treatment along with some observations regarding the quality of care for patients with cancer.


This is a very detailed report, with complex information that takes a measure of expertise and patience to understand and digest.  But there are some key highlights that are of interest, and will likely get considerable attention from the press.


For example, cancer incidence rates among men were stable from 1995 through 2002.  For women, however, the incidence rates increased about 0.3% per year from 1987 through 2002.  The better news is that for men and women, death rates decreased 1.1% each year from 1993 through 2002.  That means that although the incidence of cancer is either stable or rising, fewer patients are dying.  Earlier diagnosis and better treatment are the likely explanations for those observations.


For lung cancer, among women it appears that the numbers of lung cancers diagnosed each year have stabilized recently, whereas they had been rising in the past.  Death rates of lung cancer in women continue to increase.  What this information suggests is that women are starting to see the benefit of decreasing their rates of smoking, but it takes time to see those actions result in decreasing rates of disease from smoking.  Hopefully, death rates from lung cancer in women will decrease in the near future.


The report also highlights some of the good news about cancer treatment, and some of the problems that face us as a nation.  We are seeing more people treated in accordance with recommended guidelines.  But there are significant gaps that appear to relate to where a patient lives, their race, their access to care, and whether or not they have seen an oncologist.  It appears that consultation with an oncologist, whether surgical or medical depending on the disease evaluated, improves outcome (for example, outcomes appear to be better for women with ovarian cancer treated by a surgical oncologist as opposed to a gynecologist or general surgeon.  Women with breast cancer do better if seen by a medical oncologist).


Age also appears to be a barrier to cancer treatment.  Of course, common sense suggests that the very elderly, or those who are otherwise impaired either by serious medical or other problems may not be candidates for chemotherapy or other treatments for their cancer.  But there are many older people who could safely receive current, state-of-the-art, guideline directed cancer treatment.


What this report highlights, aside from the information about the incidence and death rates from cancer, are some of the issues we face as a country in delivering high quality, consistent cancer care.  How do we make certain that people diagnosed or being treated for cancer have access to the best available care, dictated by guidelines developed in collaboration with the experts who are most familiar with the best way to treat the particular disease?


We are on the cusp of a revolution in the delivery of health care in this country.   There has been considerable discussion about the need for electronic health records, and the anticipated benefits those records will bring to patients, physicians, and those interested in making certain patients received quality medical care.  There is a real focus by many national organizations representing patients, doctors, insurers, the government and others on developing standards for quality medical care.  After many years of “talk”, there is actually a “walk” (more like a stampede) towards implementing measures of quality medical care.  Cancer care must be part of this discussion, as well as screening, prevention and early detection for cancer in people without symptoms.


But changing the patterns of care by increasing awareness of physicians, patients and others is a huge task.  The current report outlines what we know about the right way to treat certain cancers.  It also benchmarks how we are actually doing.  And, as I mentioned earlier, we are doing better—but that is not good enough.  We still have a ways to go to be certain that women with breast cancer have the option of lumpectomy and radiation therapy vs. mastectomy; that men of color have the option of getting the proper treatment for their localized prostate cancer; that women with ovarian cancer can receive their surgery from a gynecologic oncologist.


We can do all the research in the world, all the clinical trials, and all the analysis of what treatment works best in a particular cancer.  But if we can’t translate that information into education for doctors, patients, families, insurers, hospitals and anyone else and help guide the treatment of patients with cancer in our current health care system we will have not accomplished our goal of doing everything we can to reduce the burden of cancer, and the suffering from these diseases.


So, as the annual report suggests, we are making progress.  But we cannot rest on our laurels.  We need to take information and turn it into action.  That is the only way we will see continued improvement in future reports to the nation.

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Can We Afford Medical Care?

by Dr. Len October 03, 2005

As I am sitting in a meeting discussing Medicare issues, I am reminded of a very real issue that impacts all of us, particularly our folks who are on Medicare: how are we going to pay for all of this?


We know about the advances in medical care and technology over the past years.  CT scans, MRIs, PET scans, new chemotherapy drugs and targeted drugs are only a part of the equation.  The result is that we can provide more and better care to our patients now than we ever have been able to do previously, and by some measures we provide higher quality care in the United States than elsewhere in the world. 


We cannot and should not ignore the fact that we have millions of people in this country who are either uninsured or underinsured, or that by some basic measures of health we do not measure up as well as other countries.  But this isn’t a debate about national health insurance; it’s a discussion about people getting the care they need and expect with the best technology available.


Some of the newer cancer treatments that have become available have increased the costs of treating some of the more common forms of cancer exponentially.  We are talking about thousands and sometimes hundreds of thousands of dollars.  And this isn’t for a serious, uncommon disease such as acute leukemia.  It is now the price tag for the treatment of patients with colorectal cancer, breast cancer and lung cancer.


I don’t know how people can afford these treatments.  If you are on Medicare and have a 20% co-pay, how do you meet the deductible when it can be 10, 20 or 30 thousand dollars a year and you are of limited means? Yes, some people have supplemental insurance, some are insured under Medicaid, and some people have employer-based health plans.  And many drug companies have programs that provide coverage for those most in need.


But there have to be thousands of people who are struggling with the problem of paying their medical bills for cancer treatment every day.


The crux of the issue today, as I participate in this meeting, is that Medicare is probably the single largest payer for medical care in the United States.  They have a budget for physician services and medications.  That budget is basically fixed, or in Washington terms “budget neutral.”  That means that if the cost of one component goes up, the reimbursements of the other components go down (at least for physician services and medications.  Hospital costs are not constrained by budget neutrality, so that is a different discussion.).


The net result is that as we age as a country, as we need more screening mammograms and scans, and as the costs of drugs covered under Medicare Part B go up tremendously, other parts of the fee schedule go down to compensate for those increases.


Those of us who follow this budget-dictated interaction are aware that a crisis is on the horizon.  The costs of care are rapidly increasing, and the seniors know it because their part B premiums are going to increase dramatically on January 1st of 2006.


The consequence is that on the same January 1st, physicians are going to find their fees reduced by 4.3%.  That may not sound like much to you, and you may not be concerned for the doctors, but the reality is that for doctors who do a lot of the basic work caring for patients it is a significant decrease.  Medicare has been paying below market rates for medical care for many years, and most doctors that I know have gone along and accepted that fact, as a reflection of their sense of responsibility to their patients.


Similar decreases are planned for each of the next several years.  At what point will doctors decide they can no longer afford to care for Medicare patients and keep their doors open, or to provide all of the services their patients need?


Although there have been many similar situations that have been pulled out of the hat at the last minute in Washington, in the circumstances we find ourselves this year I am much less convinced that a solution will be found in Congress before 1/1/06.


The impact of these decreases is, in reality, uncertain.  But we should be concerned about the decreased payments for the screening tests that patients need and the impact that may have on the availability of these important tests.  We should be concerned that patients have access to the best treatment available for cancer.  If these changes decrease that access, then we all will suffer.


These are problems that are not going to miraculously disappear.  They have been with us for many years, and will be with us for many years to come.  How we use our resources wisely—including the money available for health care—is everyone’s responsibility.  I have been convinced for many years that we need to utilize our resources carefully to be certain that we get the right care to the right person at the right time.  I am convinced that if we were wise consumers and providers of health care, we could extend the benefits of our medical care system to many more people.


I have always been optimistic that problems can be solved by the concerted efforts of concerned individuals and organizations.  I am a bit pessimistic about the near-term situation, which is going to be difficult.   But I remain hopeful that this potential crisis will bring forth the type of innovative thinking and discussion that, in my opinion, is long overdue, and of which we are very capable as a nation.


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About Dr. Len

Dr. Len

J. Leonard Lichtenfeld, MD, MACP - Dr. Lichtenfeld is Deputy Chief Medical Officer for the national office of the American Cancer Society.