At first glance, a scientific paper presented at the 58th Annual Scientific Meeting of the American College of Cardiology in Orlando on Saturday is reasonably straightforward. Dig a bit deeper, and the presentation highlights some of the serious issues facing us as we try to reconstruct our health care non-system here in the United States.
At heart (pardon the pun), the paper is reasonably straight forward: cancer specialists use drugs that can damage the heart. What the researchers found is that those same specialists don’t do as well as they could when it comes to detecting and treating heart failure in those same cancer survivors who have received those same drugs.
The larger question is what are we going to do to address this issue and the quality of all medical care we deliver and receive, when we don't have the strong commitment and the systems in place to get the job done? Maybe it's time for the doctors in this country to step up to the plate, admit we have a systematic problem, and commit to getting the job done.
The authors examined the records of patients treated with cancer chemotherapy drugs known to have heart failure as a significant side effect. The patients were treated at a major, highly regarded university hospital from October, 2005 through October 2007. 13% of the patients had a poorly functioning heart before they ever got the medicines, and 41% had their heart function decline either during or after they were treated.
Of the patients who either had or who developed heart failure during their treatment (75% of the patients with heart failure had no symptoms), less than half received medicines recommended for treating heart failure. Only 37% were seen by a heart specialist.
One of the authors of the study commented, “Most oncology trials that look at (heart failure)…pay very little attention to asymptomatic (heart failure). This is something that cardiologists, and certainly heart failure specialists, take extremely seriously.” Another author commented that patients need to be aware of the side effects of the drugs, and that doctors need to better screen patients for these known complications of treatment.
We have known for years, ever since some of these drugs were introduced into cancer treatment, that certain medicines can cause heart failure when used as intended to treat cancer. The first one that I am aware of that was recognized to cause this serious complication was adriamycin, which has proven to be a key drug in the treatment of several cancers since it was first introduced to researchers and then more widely used in the late 1960’s and early 1970’s.
We knew the drug was dangerous, and we began limiting the dose. We knew the drug could cause heart failure, and were alert to the symptoms. We used echocardiograms—which is a straightforward, non-invasive way to monitor heart function—routinely.
Despite all of our knowledge, patients still developed heart failure. Some have even developed heart failure years after completing the drug.
Now there are more drugs that are known to have the same complication. Perhaps the best known is Herceptin, or trastuzumab, which is used to treat advanced breast cancer as well as a preventive treatment after primary surgery, radiation and standard chemotherapy in women who have a particular genetic abnormality in their tumors (called HER2).
So it’s not that doctors don’t know about these risks. They do. But the new research implies they aren’t doing all they should be doing to evaluate and treat patients who develop congestive heart failure, especially if no symptoms are present.
And that to me is the larger message and implication of this paper: how do we create a process of care that helps medical professionals, patients and their families easily and effectively understand the risks they face from their treatments, and that they get the right follow-up care at the right time to detect and treat those complications?
This is by no means a problem unique to oncology. Similar problems with treating patients following heart attacks and those with congestive heart failure have been known for years. Those issues were in fact used as some of the first quality indicators in rudimentary efforts to measure quality medical care.
I can tell you that if you asked a room full of doctors if they do what they are supposed to do for their patients, every one would raise their hands. But studies such as this one show is that even the most well-meaning physician—and I do believe that most medical professionals are sincere in their beliefs that they put their patients’ care and interests first—still don’t do all the things they need to do for their patients.
The message, therefore, is that we need to develop systems of care that enhance the quality of medical practice in the United States. We need to do it in a way that is pro-active, non-punitive and gets the job done. Unfortunately, we remain far from that goal as I write this despite efforts underway to address these concerns.
I also believe that we as a medical profession have to take the first step in admitting that we could do better. Imagine how far that would take us in the eyes of our patients: saying that we understand we could do better, then develop the systems that enable us to do better, and hold ourselves accountable to our patients to demonstrate that in fact we are doing better.
It is my personal opinion—and has been for many years—that if we as doctors took charge of the “quality paradigm,” our image and our reputations would increase dramatically.
The other part of this equation, especially for cancer patients and their families, is to give them the information they need so they understand what needs to be done as they transition from active cancer patient to long term survivor.
We can’t lose sight of the fact that we have grown from a nation of 3 million cancer survivors in the early 1970’s to over 12 million cancer survivors today. And, in the future, as our country gets older and we see the number of cancer patients increase, we will have even millions more survivors to care for in an overtaxed medical system.
We need tools and information to allow everyone—primary care professionals, oncologists, nurses, patients, families—to have the information they need in real time to help understand the next steps in their care.
That to me is the goal we should target. It’s not just about making care more accessible or more affordable. Those are certainly important goals. But it is also about making care more effective in a process that is built on partnership, trust, and accountability through the use of information technologies and resources that are available to us right now, if we only took the time to develop them further and take advantage of them.
And let’s not leave out the need for more research like this current report, which helps us understand better the long-term consequences of our treatments and what we need to do to address the gaps that inevitably will be discovered in the future.
As a physician, I frequently hear about the incredible safety record of airlines and pilots (for which I am personally very grateful, since I fly a lot) and how we need to take some of that learning and attitude and apply it to medicine. And then I hear from the doctors that medicine is an art as much as a science, and that we shouldn’t have to practice “cookbook medicine” accordingly to some impersonal guideline that doesn’t apply to “my patient.”
Well, I think we need more of the science while we maintain the art and the sensitivity of our care (which unfortunately may be disappearing as we continue to fractionate our health care delivery). We need to “seize the day” and commit ourselves to quality care. We need to develop information systems that work, both for providing information when needed to those who need it, and monitor the outcomes and adherence to the recommendations. And, of course, we need to do this in the context of being able to provide access to affordable, effective health care.
I know it’s a tall order. I have been hoping that we would embrace this approach ever since I was a much younger medical student. I still maintain that every day we can do better. That thought remains very much alive for me, and perhaps for you as well.
When it comes to improving our health, we should never give up that hope.