Dr. Len's Cancer Blog

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Dr. Len's Cancer Blog

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Medicare Decides To Pay For Provenge, Leaving The Battle Over Cost And Value To Be Fought Another Day

by Dr. Len March 30, 2011

I bet there was a huge collective sigh of relief about the land among men with prostate cancer, their families, their physicians and especially the company involved when the Centers for Medicare and Medicaid Services (CMS)-which runs the Medicare program-announced their decision this afternoon to cover the new cancer immunotherapy treatment for advanced prostate cancer, called Provenge®, under Medicare.


The stakes are huge: I suspect the market (and cost to Medicare) will run into potentially billions of dollars, yet the benefits for all of that money at first glance seem to be modest.


Ordinarily, the outcome in favor of approval would have been as close to certain as possible. 


After all, this new treatment for prostate cancer did increase the survival of men with asymptomatic advanced prostate cancer that no longer responds to hormone treatment.  But the treatment doesn't prevent progression of the disease, there isn't much data to show that men live a better quality of life after receiving Provenge®, and then there is the key statistic: it will cost $93,000 for each treatment-without including the associated costs for doctor visits and everything else that comes along with cancer treatments.


So the specter of the government saying "No more!" to expensive drugs with "limited" benefits has passed for the moment, but I promise the debate is just getting started.  Consider this the preliminary round in a heavyweight match-up between Uncle Sam and the pharmaceutical companies that charge lots of money for their new treatments. More...

Tobacco Tourism Comes Of Age In Northeast US

by Dr. Len March 22, 2011

Know what a "dilly" is?  The dictionary describes a "dilly" as something that is remarkable or extraordinary, as in size or quality. 


The headline I came across the other day from the Associated Press story is in fact a dilly of a story.  It has some of my colleagues here at the American Cancer Society and our affiliated advocacy organization American Cancer Society Cancer Action Network more than a bit concerned: "NH, RI, NJ Buck Trend, Propose Cigarette Tax Cut."


Hard to believe, but after years of making progress in the fight against big tobacco and helping people to kick the habit or prevent young people from taking up smoking in the first place, now come proposals that would take us backwards, putting more people at risk for their lives all in the name of economic recovery.


Folks, in my humble opinion, this is one screwed-up way for states to make money. More...

We Can Run But We Can't Hide: Less (Or No) Insurance Means More Advanced Prostate Cancer At Diagnosis

by Dr. Len September 15, 2010

An article published this week in the medical journal Cancer Epidemiology, Biomarkers and Prevention and written by my colleagues at the American Cancer Society sends me a message that we can run but we can't hide. 


The topic of the research is the relationship between whether or not a man has adequate (or any) health insurance and how far advanced and aggressive his prostate cancer is at the time of diagnosis. 


The message we seem to be running from is that we continue to bury our heads in the sand at the sad truth that people without adequate health insurance are somehow less worthy of having some decent level of medical care that might save their lives, especially when viewed through the cancer lense.



New Research Report Doesn't Tell The Whole Story

by Dr. Len February 08, 2010

An article published today in the journal Cancer claims that Medicare “incentivized” urologists to do more surgery in their office, and the net result was a significant increase in medical costs for doing the procedures, compared to doing them in hospital facilities.


But, just as in all research, it’s important to get the data and the facts correct.  And when you do that for this article, you may just not come to the same conclusions.  In fact, the conclusions may be so different that one might ask whether the authors need to go back to the drawing board and update their report.


Filed Under:

Cancer Care | Medicare | Treatment

On To The Next Steps In Health Care Reform

by Dr. Len November 08, 2009

I find myself early on Sunday morning after the House of Representatives passed landmark health care reform legislation last night asking how I really feel about this momentous event.


The answer is that I actually feel pretty good. And I must admit that surprised me. 


Like you, I have been exposed to many “inputs” that have vied for my attention and have tried to influence my opinions.  I would expect nothing less, especially with something as momentous as health care reform legislation.  After all, this is a bill which inevitably will have a substantial influence on how we receive our medical care, how we provide our medical care, and how we pay for our medical care.


Some of those inputs are “pro,” some are “con” and all try to sway us into their camp as part of the political process.  Some of the sources are “distant,” but some are very “up close and personal.”


I can start in my own family, where our internal discussions about this legislation have given rise to a considerable amount of disagreement. To put it mildly, not everyone in my household thinks this version of health care reform is such a good idea.


I live in an area of the country where opposition to health care reform among physicians and my neighbors and friends runs strong and runs deep. 


I work for an organization that supports health care reform.  I belong to other organizations that have been very vocal in their support of the reform legislation, and others which are equally strident in their opposition. 


I have been glued to my computer, my Blackberry and the various news shows seeking information and opinions on the reform legislation as it moved through the House.   And I haven’t been disappointed with the variety and number of comments that I found through those outlets.


So, with all of that considered--including the personal dilemmas and conflicts--how do I finally come to grips with the realization that this legislation will truly change the landscape in this country for health care for the good and the benefit of many?


On a personal level—as reflected in one of my previous blogs where I wrote about what I wanted from health care reform—I believe this legislation will move us forward to address several of those concerns in a positive way.


I believe that the concepts embodied in this legislation will result in dramatic, beneficial innovations in health insurance and health care that will considerably improve what is now a very dysfunctional system.  I also am of the opinion that this legislation will support “game changing” advances in processes, administrative simplicity, and customer service that we have seen in other industries.  Competition, after all, is usually a good thing.


And then there were the statements of support for the legislation that came from sources that I know and trust.


Obviously, I work for the American Cancer Society.  The board of the Society made a commitment several years ago to make improving access to access to health care the leading nationwide initiative for the organization.  Comprehensive health care reform is a major part of the effort to improve access to care, and the Society's advocacy affiliate the American Cancer Society Cancer Action Network (ACS CAN) has led the charge for reform on behalf of cancer patients and survivors across the country.


Last week, ACS CAN supported this legislation after carefully analyzing what it would mean to people as viewed “though the cancer lens.”  That evaluation showed that there was much in the legislation that met their expectations and our country’s needs when viewed through this prism.  


They weren’t alone.  The AARP, other respected voluntary health organizations, the American Medical Association and numerous medical professional organizations also supported the legislation after their own very detailed examinations led them to conclude that the concepts embodied in this bill were overall good for the country. 


I keep hearing the same thing from every one of them: there is much here that conforms to our policies and our expectations.  Every one concluded that—on balance—the legislation is overwhelmingly more favorable than negative.


There are significant unknowns about the impact of this legislation, as is always the case with something as far-reaching as health care reform.


This is a bill that—if ultimately signed by the President—will be subject to regulatory interpretation.  There will inevitably be “follow-on” legislation over the years to further refine and define what we are trying to accomplish.  And that doesn’t even consider the fact that there is still a long way for this bill to travel before it becomes law, as it moves to the Senate followed by the conference committee followed by reconsideration by the House and the Senate before it is signed by the President.


So now we move on.  We are not finished with this process, and there is probably going to be a considerable amount of discussion and drama as we go to the Senate and the conference committee.


Maybe we are finally on the cusp of making a real difference in the lives of real people.  Maybe we are on the cusp of getting reforms that will work, and which will expand access to health care for people in this country who have no hope today of getting the health care they need.


And just maybe we are on the cusp of fulfilling my own long-held dream of developing a truly American solution to providing adequate, affordable, quality health care to every citizen. 


Let’s hope that in the spirit that has made this country great, we will not lose sight of that very elusive goal. 


Let’s continue to craft that truly American solution, one which will make many of us proud that we worked towards providing an answer to a fundamental need that will improve the health of our nation and benefit us all.








Filed Under:

Cancer Care | Medicare

"Gee Whiz" Cancer Surgery May Not Be Best Surgery

by Dr. Len October 14, 2009

I have a confession to make: I am not a big fan of “gee whiz” medical technology.  At least not until it is proven to really make a difference in the care we provide our patients, or the outcomes of their treatments. 


A study in yesterday’s Journal of the American Medical Association comparing the side effects and outcomes of prostate cancer surgery using the robot to more traditional surgery reinforces that notion. 


Using the robot to treat prostate cancer surgically may be better in some respects, but not better in others.  And maybe not better enough for you to listen to all of the advertising hype about the robot, and forego treatment from a urologic surgeon who in fact may be more skilled at the operation and not use the robot.


The study was reasonably straight forward.  The researchers looked at patient information they obtained from a highly respected national cancer database called SEER and matched those men diagnosed and treated surgically for prostate cancer with another set of data obtained from Medicare fee-for service Part B billing records.


Once they matched the men in both sets of records, they looked at factors related to treatment and outcome, such as how long the men stayed in the hospital and what complications they had over the year following their operation.


Their goal was to evaluate men who had surgical treatment for their prostate cancer one of two ways: with the robot, which is called “minimally invasive radical prostatectomy”, (MIRP) done with instruments passed through small holes and manipulated by a urologist who is sitting at a special machine, compared to men who had their surgery the more traditional way, called “retropubic radical prostatectomy” (RRP) where the surgeon is standing directly by the patient and operating through a more typical (but still fairly small) incision.


Both of these operations remove the cancerous prostate, and--when appropriate—allow the surgeon to remove lymph nodes nearby the prostate.  Both are designed to reduce the risk of impotence, which many years ago was a common problem for men who had prostate cancer surgery before newer types of surgical treatment were developed.


The robotic surgery is very new, and has only been used to any significant degree to treat prostate cancer since the early part of this decade.  But it clearly has caught the attention of the public, and hospitals across the country can’t seem to wait to get their hands on one of these machines and advertise that they are a “robotic center” to accommodate the patient demand.


The problem is that these machines cost millions of dollars, and the disposable equipment sold for each operation has made the company that supplies these machines a heck of a lot of money.  That in turn means more costs for hospitals, health insurance companies, and ultimately the patients.  It also takes longer to do the robotic operation, according to my colleagues who perform this surgery.


So, whether or not these machines are really worth it is a very important question.  Not to mention that the increasing concerns about the value of the PSA test has run head long into the reality that prostate cancer treatment in this country has turned into a huge business for doctors and hospitals—whether or not the treatment is necessary.


(That issue was highlighted recently by a hospital in Philadelphia offering PSA screening to men 35 years and older, despite absolutely no proof that this was of any value to men in this age group. As with most community screening fairs run by hospitals, I suspect that one of the major drivers for that campaign was probably to “feed the beast” rather than offer scientifically valid screening to men at risk.)


So what did the study find?


There has been a huge increase in MIRP from 9.2% of prostate cancer surgeries in 2003 to 43.2% in 2206-2007.  However, if you were poor and/or black or Hispanic and/or less educated, you were less likely to get one of these fancy surgeries. 


You were likely to spend one day less in the hospital with the robot (2 vs. 3 days), less likely to have a blood transfusion after surgery, and more likely to do a bit better with regard to surgical complications post-operatively.   But the authors also suggested that the number of days in the hospital may in fact be similar in high volume hospitals, so whether or not this difference is “real” is not certain.


Another wrinkle to consider in this study was that many of the robotic procedures in this study were performed in Detroit and California, which the authors point out are high volume robotic centers.  This may have contributed to the better outcomes for MIRP, compared to RRP which is done by more surgeons in more locations.  As they say in the weight-loss commercials: “These (robot) results may not represent the typical experience with our product”.  (Detroit, in fact, was one of the “homes” of robotic prostate cancer surgery because of a surgeon there who was nationally renowned for his early work with the robot.)


But the robot did not fare better on every measure.


You were over twice as likely to have a problem with your urinary tract after the robotic surgery, and have a higher risk of urinary incontinence (controlling your urine flow) compared to the non-robotic technique.  Your risk of having impotence after the robot surgery was about one in four, compared to one in five with the more traditional surgery.


Unlike a previous study where the men operated on with the robot were more likely to have an earlier relapse of their prostate cancer and require additional treatment for the spread of prostate cancer compared to men who had traditional surgery, this study showed that both groups did the same.  When it came to the control of prostate cancer, there was no advantage to one type of surgery compared to the other.


So what do you do if you are a man diagnosed with prostate cancer who has made an informed decision to have surgery for your disease?


I guess for some of you the decision will come down to the old adage “you pay your money and you make your choice.”   You may decide that how long you stay in the hospital is more important than the difference in whether or not you can control your urine flow or are able to have sexual relations.


But I think there is a more rational recommendation that actually may surprise you: I suggest you find a surgeon who does either procedure regularly and has done hundreds—if not thousands—of prostate surgeries for cancer.  To me, it is experience that counts not whether the procedure is done with or without the robot.


The bottom line is that you can have a great surgeon who doesn’t use the robot, or a lousy surgeon who uses the robot—and vice versa.  The robot does not make an inexperienced surgeon better.  It’s that simple.


Take a moment to read this information that was contained in the JAMA paper, and read it carefully.  It is very informative and something that every man considering prostate surgery who has succumbed to the advertising and hype surrounding this robotic procedure needs to know:


“For surgeons eager to add robotic-assisted MIRP to their armamentarium, there are few barriers to entry: surgeons must attend a 2-day course before scheduling cases proctored by another surgeon who has performed at least 20 robotic-assisted MIRPs.  Requirements may be less rigorous for attaining hospital privileges for MIRP without robotic assistance*.  Studies estimate the learning curve for either approach is at least 150-250 cases, and greater RRP or MIRP surgical volume is associated with better outcomes.”      


(*Note: That means doing the prostate surgery laparoscopically without using the robot)


I would suggest that if you need to get surgery for your prostate cancer using either type of surgery, you make certain you are not case #21.  You should be at least case #250, and I would prefer to be case #500 or higher. 


Here is what the authors have to say in concluding their report:


“In light of the mixed outcomes associated with MIRP, our finding that men of higher socioeconomic status opted for a high-technology alternative despite insufficient data demonstrating superiority over an established gold standard may be a reflection of a society and health care system armored with new technology that increased direct and indirect health care costs but had yet to uniformly realize marketed or potential benefits during early adoption.”


In other words, many of us buy the hype and forget the reality that just because it looks fancy doesn’t mean it really gives you a better result.  We are medical consumers run amok, dazzled by ads and unsubstantiated claims rather than by science and documented outcomes.  If we see it on TV or a billboard, it must be better.


The science tells me it is the experience of the surgeon that counts, not whether the doctor can play video games. 


So, if you decide to get your prostate taken out because you have cancer, go with a surgeon that has done the surgery lots of times, whether or not they use a robot.  You don't have to be uncomfortable if you want to leave the video games to the kids.



"Euthanasia" Is Taking The Debate Too Far

by Dr. Len August 11, 2009

The debate about euthanasia has gone too far.


Someone’s intent to do a good and necessary deed has now been transformed into a hideous misrepresentation that not only affects our humanity and dignity as a nation, but goes to the heart of the physician/patient relationship and the responsibility that physicians have to provide healing and comfort as well as treatment. 


That’s our oath, and that’s what we are supposed to do.  Recognizing that imperative is not something that should be punished as an evil act.


Perhaps some background would be helpful in framing the issue:


Medicare is supposed to only pay for medically necessary and effective care.  It is not allowed to provide other services such as screening or prevention unless specifically authorized by Congress.  End of life counseling falls under the category of non-covered services, but probably gets into the payment mix as part of other billing codes which doctors use to get paid for more routine “evaluation and management” services. 


Providing explicit payment for this service will encourage appropriate and needed discussions between physicians and patients on this very important, difficult and humanitarian topic.


For years, many of us have been concerned about end-of-life issues, such as living wills, pain management and hospice care.  Counseling our patients as they age about their options—and equally important, understanding what our patients’ wishes may be—is an honored part of the physician/patient relationship, especially for primary care internists, family physicians and oncologists.  The reality is that we have not been as successful as we need to be in encouraging these discussions.


We have tried for years to get people to sign living wills and provide durable powers of attorney for health care.  Medical professionals need guidance—preferably in advance of the moment--on what patients want done, either at the time when their lives are coming to an end or when they may not be able to speak for themselves.


There is nothing inhumane or inappropriate about that discussion.  It is a discussion that no one wants to have, and one that is never easy.  But it is the right thing to do, and there are plenty of medical and patient organizations who have devoted considerable effort to encourage these discussions.  There is nothing about the discussion that is preordained to limit care.  In fact, some patients and families want “everything done” even when medical professionals find that directive to be against their own ethical instincts.


I learned these lessons early in my career as a medical oncologist.  Having discussions about end-of-life is an unfortunate reality in cancer care.


What surprised me at the time—when there was less I could do for many patients than is the case today—was the number of patients and families who told me they were more interested in comfort than they were in treatment.  They wanted to be certain someone would be there to care for them through their last days or months and ease their pain and suffering more than they were concerned about getting the next drug which more likely than not would have given them more discomfort that hope and relief from their suffering.


Those discussions had an incredible impact on me as a person and a physician, and the experiences remain with me today.


I didn’t euthanize anyone, and never, never would such a thought enter my mind.  My patients taught me that having a heart beat and being alive to see the sun rise another day was not living and was not life.  That was their decision, not mine.  I would do what they wanted, but almost always what they wanted was care, compassion and relief from pain. That is what we tried to offer.


When I recently heard the gross misrepresentation surrounding the portion of the health care bill that referred to paying health care professionals for these end-of-life discussions, I couldn’t help but be concerned and confused.  When I heard the rhetoric stormed up to a level of “death panels” and “Nazis” I knew we had gone too far.


I have stayed out of the politics of health care reform in these blogs, and will continue to do so.  But as I mentioned in my comments the other day, someone has to be an honest broker of what is going on out there, dealing with some of the rhetoric that is coming from both sides and which is designed to inflame rather than inform.


If you are a physician who has cared for a patient for years or even decades, you know that person as a friend as well as a patient.  Your goal is to provide the best care you can, but also to provide comfort when cure is no longer the goal.  You counsel your patient and their family on what you think the best path may be at that moment and in the future, whether it be treatment or comfort.  You act as protector for their wishes, the guardian of their health, and at the appropriate time the minister for their comfort.


You are not a Nazi.  You are not triaging who will live and who will die.  You are not some thoughtless bureaucrat who is concerned about how much it will cost to keep someone alive.


I have stood in the places of remembrance for people who were killed without cause.  I have cried my tears over those who were lost by senseless murders.  I have read the writings of those who survived.  And I will never forget.


So please do not dehumanize the memories of those who suffered from terminal illnesses or the ravages of age by suggesting that somehow our great country, our great people, and our great physicians and health professionals are somehow going to become agents of the state and in turn agents of death. 


Please understand that dignity in our lives must always be paramount in our thoughts.  Discussing end-of-life wishes is humane and appropriate.  Providing counseling, care, hospice and pain control is in the noblest traditions of our profession and our country.  Listening to our patients and their families is what we do, and what we pledge to do.


Continue with the debate and the discussion, make your case and make your points, but do not dishonor those of us who have tried to do the right thing for our patients, families and friends and the memories of those who have died in peace, honor and dignity by make the choices that were best for them.

Filed Under:

Cancer Care | Medicare | Treatment

What I Want From Health Care Reform

by Dr. Len August 08, 2009

I suspect I am one of many who are not unhappy that Congress has finally taken their August recess.  I suspect I am also one of many who are alarmed and upset by the next act in this play, which is the rancor and near-violence we are seeing on our TV sets every day at the various town hall meetings when health care reform is the topic of discussion.


This isn’t what health care reform—or whatever you choose to call it—is supposed to be about.  This is a serious matter for our nation and for many of our fellow citizens. It deserves thoughtful and deliberate discussion.


The events of the past several days have left me distressed and concerned.  The anger, the accusations, the lack of decorum and the distortions and occasional “untruths” being promoted by all sides have left me dismayed.  It is even beginning to affect relationships among friends and families.


All of this has led me to think about what is important to me, and for my family.  What do I really want from health care reform? 


1)      I want to know that I can get health insurance.


Sound simple?  It really isn’t. 


I have been in a medical practice or otherwise employed most of my adult life.  I have always had health insurance for me and my family.  I have had the opportunity to pick my plan, and pay more to my employer and a bit more in co-pays and deductibles so I could get the coverage I wanted. 


But I can not let go of the thought that I am one step away from disaster.


If I had to go out into the private market today, I would have difficulty getting insurance.  Why?  I have a couple of fairly common medical problems.  I am older.  Members of my family also have some medical problems.  I suspect we would be “rated” and pay through the nose if we had to purchase our own insurance, if I could even get it. 


I have “pre-existing conditions” and despite my efforts to take my medications and exercise regularly to keep those chronic conditions under control, there aren’t many companies who would welcome me with open arms.  I am a “high risk”, despite doing what I am supposed to do to avoid a more serious medical problem. 


But what if I had cancer?  What if I had heart disease?  What if I had type 2 insulin dependent diabetes?  Do you honestly think I could get insurance anywhere other than through my employer?  And if I was in a small business—such as a medical practice—can you imagine what my illness would do to the premiums of my company?


We know that these scenarios are not unusual or unique.  Listen to the stories, read the studies, talk to the people who have faced the problems.  These are real issues, and these are everyday occurrences for honest, hard working people that are right there in your community.  They are your neighbors, they may be your friends, and they may be your family.  They are not fictional, and they have a very real interest in the outcome of this debate.


2) I want to be able to afford insurance.  I want the system to be more effective in terms of quality and less expensive (or at least reasonable) in terms of cost.


We are out of control when it comes to spending on health care.  That’s it, plain and simple. 


People who want insurance and need care can’t get it; some people who have insurance want everything.  Doctors say that they have to do all the tests they do because of “defensive medicine,” yet we don’t talk seriously about tort reform.  And even if we had tort reform, I don’t believe that it will resolve the issue of over-ordering tests and procedures. 


Quality of health care is not top of mind for the medical profession in this debate.  We order too many tests and studies too often without evidence that they make much difference.  We can spend thousands of dollars on scans, but can’t afford dollars for vaccinations or “well care.”  We install imaging machines in offices to make more money, because our physician payment system distorts the incentives substantially in favor of doing more tests.


We talk about the “savings” that will come from the widespread use of health information technology, yet we don’t have standards that will allow computers to talk to each other.


We pay lots of money for doctors and hospitals to do things.  We pay a pittance for those who try to prevent disease, and we pay relatively even less to those who are charged with trying to coordinate the complex medical care of seriously ill patients. 


We need to promote preventive medical services, pay adequately for our necessary (and at the very least) basic medical care including primary care, obstetrics/gynecology, and general surgery.  We are losing doctors in these specialties, and it will take decades to replace them.


3) I want to know what I am being charged for when I receive a medical service, what my insurance covers, and what I owe in clear, understandable language. I want to know those fees are reasonable for the service provided.


We are charged substantial fees for some medical services, and as ordinary people we have no idea whether or not that fee is reasonable or the service is appropriate. 


I recently got a bill for the treatment of a member of my family.  Two 1 centimeter superficial lacerations resulted in a $1700 bill, including a remarkable physician charge which was in fact “upcoded” (that means the doctor “coded” for a service that was a higher level code than appropriate for the service that was performed.  I assume it was an “honest” mistake, because if it wasn’t it would be fraudulent).  The skin glue was charged out at about 9 times the purchase cost available to me on the internet.


I get hospital bills that simply say “pay us money”.  No itemized bill. No insurance bill or statement, just pay us the money. 


Patients go to doctors, who look at you sideways if you ask in advance what their charges are for their services.  Keeping their fees secret has been a long tradition among my colleagues, and in private conversations they tell me they should be able to charge whatever they want to.


Some physicians say that we should individually contract or negotiate the costs of our medical care. The man I cared for a couple of weeks ago on an airplane was in no position to negotiate the costs of his care as the emergency medical technicians wheeled him off the plane on his way to the hospital.


Hey, folks, here’s a bulletin: there IS no private market in health care, except for cosmetic and concierge services.  Patients are at an incredible disadvantage in understanding the costs of their services. There is no transparency regarding the costs of medical care and services. The prices are jacked up for those who pay because others can’t—or don’t—pay their bills. 


My personal experience confirms that you have to go to incredible lengths to get answers to even simple questions, and I am considered an expert in this stuff.  If you are an “ordinary patient,” I can’t even begin to imagine how you would understand the charges and the payments.


4) I want to know what treatments and medicines work, what doesn’t work, and if we know whether or not it works.  I want to know that I am getting appropriate, quality care for my medical problem


That is NOT rationing.  It is information.  We need more of it.  We are doing too much of what doesn’t work, too little of what does work, and who knows how much of what may or may not work.


It may be a surprise to some of you, but there are many thoughtful physicians and top-tier medical professional organizations who have been clamoring for this type of research.  I have said this publicly and will say it here: It is time to understand that just because a doctor recommends something, doesn’t mean it works or is the right treatment for you.  But you (and too frequently even your doctor) don’t know that, because the research hasn’t been done. Think about hormone replacement therapy, and you will understand what I am saying.


Here’s another bulletin: In too many circumstances, you have no way of knowing whether or not you are getting quality medical care. 


Too often you as a patient have no way of knowing if you are receiving the right recommendations for your health, whether or not there is a less invasive or less expensive treatment option, or whether the treatment has been shown to effectively treat the condition you have.


The medical profession should embrace quality, quality improvement, transparency, and accountability to demonstrate they are providing the best medical service.  Unfortunately, this has not been exactly at the forefront of the discussion about health system reform.  If it was, I would venture that patients and those who foot the bills for these services would greet the effort enthusiastically and reward health care professionals appropriately.


5) I want confidence that my insurance will be there when I need it for a serious medical illness.


We have too many instances—and too many bankruptcies—where “satisfied” people suddenly found themselves not so “satisfied.”  I am willing to bet that you (and me) have no idea whether or not your insurance will be a facilitator or a barrier to your care if you or someone you love becomes seriously ill with a disease like cancer.  You just don’t know. 


So don’t stand there and rail against your Congressman or Senator because you are “happy” with your health insurance.  I wonder how many of you have had a serious, prolonged illness in your family.  If your experiences have been positive, terrific.  But don’t discount that many others have not been so fortunate.


I am looking for someone who is a “trusted voice” or “honest broker” who can bring this discussion and debate about health care reform back to the center, who can tell us what is in the bills and what is not.  Too many lies, too many untruths and too many distortions have me feeling there is no such voice being heard in the land today.


Then there is the question of what we are really talking about anyway.  There isn’t one bill about health care reform; there are several.  And there is one that hasn’t even made it to the public.  (I find myself hoping against hope that those six senators will have the wisdom to get this close to “right” so we can have something that will ignite the passion of those of us who want something done, yet want it done with balance and the participation of both sides of the aisle.)


When this discussion started several years ago, the American Cancer Society had four principles that were core to the Society’s efforts surrounding health care reform.  On reflection, those four principles articulated at that time are consistent with what many of us want today: 

  • Adequate—Timely access to the full range of evidence-based health care, including prevention and early detection.
  • Affordable—Costs are based on the person’s ability to pay.
  • Available—Coverage is available regardless of health status or prior claims.
  • Administratively simple—Processes are easy to understand and navigate.

Aren’t those principles what this is all about?  Can’t we focus on those principles and move this process forward?  Is it really that difficult to get this done?


We need some sanity in this discussion.  We need to think as individuals, communities and as a nation about what is important to us when it comes to health care reform and our health care in general.


I suspect there is a sense in the country that many of us are willing to “pitch in” if everyone pitches in.  This shouldn’t be about us against them.  This shouldn’t be about “I’ve got mine and you can go to h---.”  We are better than that as people and as a nation.


It’s time our public discourse and our political/legislative process should reflect the best of what we are as a nation.  We need to get this done.




Filed Under:

Cancer Care | Medicare | Treatment

The Cost and Value of Health Care

by Dr. Len July 20, 2009

I have been thinking over the past several weeks about a topic that is very near and dear to the hearts of many of us, and that is the cost of health care.


Let me put a couple of my longstanding, personal guiding principles on the table for your consideration:


1)      We spend way too much on “health care” in this country, and don’t get value for what we spend. 


2)      I do believe that there is sufficient money within our current health care spending to provide better care to more people at lower cost.


I know I am not alone in those thoughts.  The problem is how we move from the reality of today into the vision of tomorrow, and improve the quality of the care we provide while we create a system where the costs of that care more reasonable and rational so we can extend more care to more people.


A couple of weeks ago I was in Washington DC and participated in a panel on health care reform for volunteers attending the annual meeting of the Ovarian Cancer National Alliance.  I showed a slide during that presentation that I have shown many times before.  The slide details the per-person spending for health care in about 30 developed countries and compares it to life expectancy. 


When you look at the slide, what you quickly see is that most developed countries in the world spend within a fairly limited range per person per year on health care.  One country stands out however, and that is the United States.  It ain’t even close:  we spend a lot more than other countries per person on medical care.


Maybe that wouldn’t be so bad if we had a life expectancy to show for it, but we don’t.  We are actually near the bottom of the pile when it comes to the number of years the average American lives compared to other countries.  We are actually right next to Cuba, who spends almost nothing on providing health care to its citizens.  (By the way, Japan leads the list with about 80.5 years per person.)


Usually when I show this slide (which was prepared by my colleague and Chief Medical Officer of the American Cancer Society Dr. Otis Brawley), it gets some attention from the audiences, which are usually made up of people familiar with the subject such as doctors or human resource directors. But this time, there weren’t a lot of doctors in the audience, just committed volunteers committed to their cause. 


There was an audible gasp and reaction in the room when I explained the slide.  Clearly it struck a chord.  It is that graphic a representation of where we have failed to get “value” no matter how much we pay for “health”.


We have the most expensive health care in the world and we have the most technologically advanced system in the world (at least with respect to machines, but certainly not in relation to health information technology).  But if we tried to measure the quality of the care we provide, the fact remains we would have an impossible task to show that we offer a reasonable quality of care for the money we spend.  There is simply very little accountability built into our processes of providing medical care.


Now I don’t want to imply that a lot of doctors don’t care about their patients.  They do, and they are for the most part exceptional, committed people.  But listen carefully to all the discussions surrounding the current health care debate, and most of what you will hear is about money and costs.  No major medical organization—pro or con the larger issue of health reform—is out there waving the quality flag in front of costs and income.  They just aren’t doing it.


And yet accountability and quality are really at the heart of the issue.  Getting the right care to the right person in the right place at the right time would take us a long way to getting our arms around the problems we face when it comes to providing affordable, accessible quality health care.


It’s not just the doctors who are responsible for this dilemma.  Talk to them and you hear about patients demanding all sorts of treatments, even to the extreme of sending someone to the intensive care unit when they are near death with no reasonable options remaining.  You constantly hear docs talk about defensive medicine, and the fear of being sued for not doing every test possible. 


I call this “zero order” medicine.  Zero order meaning nothing is left to chance, and nothing is left to judgment.  It means every test possible is expected, and gets done or risks a malpractice suit.  It is a love affair with technology that implies that if the test is done with fancy equipment, it will work better and tell us more than perhaps doing nothing for the time being.  It means there must be one more medicine available that is going to cure a cancer, or one more stay in an intensive care unit that will allow a lung to breathe on its own once again, after years of damage from smoking.


A couple of examples recently have refocused me on this issue. 


One example was an article in the New Yorker magazine where a doctor eloquently described the differences between two towns in Texas, and where he tried to figure out why health care was about twice as expensive in one town vs. another while there was no significant difference in health care outcomes by any measurement he could determine.


Another was an article in the New York Times recently where the reporter asked if we were getting our money’s worth from very expensive prostate cancer treatments compared to “watchful waiting.” He noted for many men it was not possible to demonstrate that one approach to prostate cancer treatment (depending on the underlying characteristics of a man’s prostate cancer) was necessarily better than the other, while some of the more “advanced” approaches were incredibly more expensive.  (And this is in the face of recently reported research which has shown that it is very difficult to show a real difference in survival as a result of prostate cancer screening.)


There are research studies that show prostate cancer is found with about the same frequency in men who are screened vs those who are not (and were biopsied anyway as part of a research study).  That has led some of us start asking the question what difference does PSA testing really make? 


And then there is the fallout from a number of prostate cancer survivors (and doctors) who are upset about what we say, since many of them believe—because they have been led to believe—that the PSA test in fact saved their lives. 


So where is the honesty that can say to men that maybe the PSA test did save your life, but there are many more men who had the test and debilitating, expensive treatment where it didn’t make a difference because we can’t tell you whether or not your prostate cancer would have been a “bad” one?


Here is another example:


I returned from vacation to find a letter on my desk—sent certified mail to me and a number of other thought leaders in medical oncology—from a woman who had a strong family history of breast cancer.  She had discovered a lump in her breast and saw her doctors.  She had a mammogram and ultrasound which were inconclusive as to whether or not the lump was a cancer.  One of her doctors—a breast surgeon by specialty—ordered an MRI of the breast. 


The bottom line of her letter—with the supporting documents—was that her insurance company had denied the MRI.  The woman thought that was terrible.  She wanted the MRI, her doctor had ordered the MRI, and the insurance company had denied the MRI.  Her argument was that she should have been allowed to have the MRI, which I believe she eventually did get.


I read the insurance company letter, and guess what:  I think they were correct.  The mammogram and the ultrasound were inconclusive and cancer could not be ruled out.  They very clearly stated that medically she needed to have a biopsy.  The MRI wouldn’t help make that decision.  


They made the exact correct recommendation.  There was nothing about the MRI that should have deterred the physician from proceeding with the biopsy. She needed a biopsy of the mass.  That's what the insurance company said.  Medically, it was the correct recommendation.  From my view, it had nothing to do with cost.  It did have to do with "good medicine."


But, you may say, patients aren’t doctors.  They want to do what their doctors say they should do.  They say, “Dr. Lichtenfeld, you are a trained physician.  You have much more knowledge than the average person.”  Yes, that’s correct.  I do.  And so did the doctor who recommended the MRI.  I just hope the MRI wasn’t in the doctor’s office, which I have seen advertised by other “breast specialists” or in a hospital that employed the surgeon who made the recommendation.


By the way, I haven’t seen in the correspondence that anyone who saw this lady suggested she have genetic counseling for the BRCA test.  Her history certainly suggested that would be appropriate.


In another example, I sat next to a very healthy and admittedly active gentlemen in his mid-30’s on another plane flight.  He was a successful consultant and exercised regularly.  He appeared very fit.  He told me about his back problem, which flared about once a year for a couple of weeks and then resolved.


For the past four years, he would see his primary care physician when the problem recurred.  Every time, his primary care doc sent him to a back specialist, who ordered an MRI.  Every year the report came back that they cannot identify the cause of his pain.  The back specialist recommended an over the counter pain medication and told him to call if it didn’t get better. He always got better.


Having treated a fair number of patients with low back pain just like his, I asked him if anyone—particularly his primary care physician—ever had a conversation with him suggesting that he didn’t need the MRI or have to see the back specialist if his pain hadn’t changed or resulted in certain neurologic changes?  Or, that even if they found the cause of the pain (something like a bulging disc) most surgeons wouldn’t operate unless there was severe, unremitting pain or a change in his exam?


The answer was “no,” and the gentleman indicated his frustration that he went through this every year, and all he got was a suggestion to go get and MRI and some NSAIDs.  I asked how he felt about the necessity and costs of the MRI—which probably would be billed at a couple of thousand dollars—and he said that didn’t bother him.  After all, he said, the specialist said he needed it and who was he to argue with a doctor?  As to cost, he only had to pay $100, so why not get it?


I could go on and on—including the $1100 bill someone I know very, very well faces for a recent emergency room visit for a daughter who was injured while volunteering as a waiter at a faith-based camp.  The bill was for medical services provided to her when she broke a glass in her hand and had to go to the emergency department for an examination, in an overabundance of caution.  In the ED, she was found to have two minor lacerations with no shattered glass in them, and she had some surgical glue applied to each laceration.


The cost?


  • $62 for a vial of generic local anesthetic
  • $109 for each of two surgical glue packets
  • $339 for a low intensity emergency room doctor bill
  • $244 for the use of the emergency department.  


What would Medicare have allowed for the $339 doctor visit?  The answer: $39.31.


That’s right: they charged the young lady almost 9 times what Medicare would have paid for the service.


I tend to be an optimist.  Some people might say I believe in the tooth fairy (maybe it’s a carryover from the days when I played tooth fairy for my children).  I have hoped for a long time that one day the folks that are engaged in health care would wake up and develop a sense of rmission and reasonableness when it comes to what they do, how they do it, and what their responsibility is to their patients—both with respect to quality and costs.  Take the best practices and spread them around the country so everyone can benefit.  Demonstrate that as a profession we take quality seriously as a core part of our work.


Would it be so hard for someone to say that a test or x-ray may be useful, but in fact it is reasonable NOT to do the study?  Or to say that we really don’t have the evidence to support the usefulness of a test that a patient may want?  Or that we find a way to protect those doctors who make good decisions in line with well thought out recommendations and guidelines, even if the eventual outcome may be that 1 in 10,000 chance of having missed something?  Or that we learn—once again—on how to do a history and physical and advise our patients of their options, and engage them in a learning process together so they don’t go off and spend thousands upon thousands of dollars needlessly and with blind faith that the next test is the best test?


Is that asking too much?


I suspect it is, and unfortunately I don’t have an easy answer.  There are places in this country that provide high quality, evidence based medical care.  It is part of their core mission.  The amazing thing is that these places are recognized as providing some of the best care in the country, but they frequently do so at substantially lower cost.


As a country and its citizens, we desperately need to rethink how we do this.  I would prefer that we do this rationally and voluntarily, and commit ourselves to partnership, shared understanding of risk, quality care, fiduciary responsibility to each other and accountability for the care we provide and the care we receive. 


But I fear—after almost 40 years of hoping to the contrary—that we aren’t going to see that day anytime soon. 


I guess I will just have to accept the fact that the tooth fairy is a fiction, after all.



Filed Under:

Cancer Care | Medicare | Treatment

Thank You, Mr. President!

by Dr. Len June 25, 2009

Last night was a special moment for me: I was one of those 164 people representing the “face of America” that was in the East Room of the White House as Charlie Gibson and Dianne Sawyer from ABC News interviewed the President as he answered questions about health care reform.


My bottom line conclusion?  This guy knows his stuff.


You may have already seen the telecast or snippets on the morning shows (if you can get past the lead story about the Governor from South Carolina).  If so, there isn’t much I can add to what you have already heard.  But what I can say is that—aside from the glamour and imposing “presence” of the room itself—I was overwhelmingly impressed with the President’s grasp of the issues and his ability to respond effectively if not always completely to the questions he was asked.


I have been through this before.  I have been “in the room” when political figures address audiences and promote their policies.  And, like you, I watch television from time to time, see the debates, listen to the Sunday morning talk shows, and draw conclusions as to whether I agree or disagree or whether I like or don’t like (or don’t really care) about the person who is the target of an interviewer’s probes.


I have over the years become somewhat blasé and perhaps a bit cynical about “the show”.  The answers are frequently scripted and perfunctory, repeating the same sound bites again and again.  They are—in a word—predictable.


One could make the argument that the President’s responses last night had some of that same predictability.  But although the interviewers and the questioners had their scripts in hand (it appeared that the people who appeared on camera had been selected after having submitted the questions in advance, since the hosts knew who they were looking for and those people were positioned in certain accessible parts of the room), I don’t believe the President knew what was coming.


That’s why I believe his presentation was in fact what I would call a “tour d’ force” on health care reform.  You may not agree with him (I won’t tell you here which parts I thought were right on target and which ones gave me pause), but you can’t fault him for not knowing his topic. 


This man sat there for 90 minutes and took on every question he was asked.  And although some of us in discussions after the show recognized where he did a little bobbing and weaving, almost to a person we thought he was masterful in his ability to articulate his position.  And those comments came from some of the most knowledgeable Washington health care “players” that I know.


That, my friends, is what I would call “high praise.”


It is clear that this President means what he says about advancing health care reform.  Looking at him up close and personal—and I was close if not personal—I can tell you he didn’t flinch, didn’t recoil, and didn’t react adversely to any question (although I did think his answer about basing health care policy decisions on a person’s “spirit” to live put him in a tough spot).


So, if I had the opportunity, what questions would I have asked?


First and foremost, I would have thanked him on behalf of the Society and the millions of people and their families who are confronting cancer today for making the issue of accessible, affordable, quality health care a priority of this administration, this Congress and this nation.


I would have asked how his proposal would have helped the Americans who spend themselves into poverty treating cancer and other chronic diseases. 


Our advocacy affiliate, the American Cancer Society Cancer Action Network recently completed a survey that showed 20% of American families spend most or all of their life savings when faced with paying for cancer treatment, and one out of seven families accumulate thousands of dollars of uncompensated debts as a result of a cancer diagnosis. 


The diagnosis of cancer not infrequently—and unfortunately—brings with it huge personal financial burdens and all too often outright bankruptcy.  We can’t have people going through their life savings while fighting for their lives.  It’s almost like being in a fight with one hand tied behind your back, although in the case of cancer the consequences are much more serious.


I would have asked how we can make certain that everyone has access to preventive services, so we can find cancer early when it is most treatable and offers the best prognosis.  Too many people have to put off or never get recommended screenings for cancer because they simply can’t afford them or don’t have health insurance that covers them.


My next question would have been about the portability of insurance coverage, and how to maintain affordable, effective health insurance even if you are too sick to work. 


The platitudes about COBRA and how it protects us makes me want to…. (fill in the blank, because I can’t write the words I would like to say here).  I have been out of work in the past, and even 10 years ago the cost of maintaining health insurance for my family was over $12,000.  Without an income and not much savings, that was a very, very large number.  A member of my family recently graduated from college, and the cost to insure her was enormous.  She is now among those 46 or 47 million uninsured they talked about last night.


Being sick with cancer and losing your job is bad enough.  Paying through the nose for health insurance after you lose your job makes it worse.  Talking dispassionately about how people can maintain their coverage in those circumstances as though this was a simple mechanism at a reasonable cost just doesn’t cut it with me.  I guess you could say that this particular issue is personal.


The final question would have been what protections will be put into place to be certain that people have health insurance that is adequate to meet their needs if they have to be treated for cancer.


Too many folks find out too late that their health insurance has a variety of limitations and maximums that simply don’t cut it in today’s expensive treatment environment.  When you have drugs that cost over $100,000 a year each, and scans that cost over $3000 each, you find out that what you thought was a lot of coverage can disappear very, very quickly.  We need to provide assurance to the American people that they have adequate coverage for the prevention, diagnosis and treatment of cancer, from the very first step to the very end of life.  No one—and I mean no one—wants to have cancer.  And no one should be left unable to afford effective, quality based, adequate treatment for their disease.


So those were the questions I would have asked the President, and you can decide for yourself whether or not he answered those questions in response to the ones he was asked last night.  And if you didn’t hear the answers, maybe you can ask those same questions yourself and decide whether or not the various plans you are hearing about every day meet the tests outlined above.


Let’s finish here on a perhaps more humorous note, which is the “other comment” that I was prepared to make.


If you know me, you are aware that I look somewhat like Phil Jackson, the coach of the Los Angeles Lakers who recently won the NBA championship. Knowing that the President is a basketball fan, I was prepared to respond if he made the comment I have heard many times before, namely “Do you know you look like Phil Jackson?”


My response to the President would have been, “Sorry, Mr. President, but I’m not Phil.  However, my colleagues at the American Cancer Society, our advocacy affiliate the American Cancer Society Cancer Action Network, and our millions of volunteers across the country would like to bring home a more important championship, which is accessible, affordable, and adequate health care reform for everyone in this country.”


That is something all of us could celebrate.


Mr. President, thanks for inviting me to your “House.”

Filed Under:

Cancer Care | Medicare | Treatment

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.