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Sequester and Cancer Treatment: Time for Change

April 28, 2013

Bill Postmus whines for the established outpatient oncology industry:

What has happened is that with Medicare reimbursement cuts, profitability of treating patients in the office has allegedly zeroed out.  Private clinics that used to rake in obscene profits 20 years ago, and comfortable profits 10 years ago, now not quite struggling but certainly doing marginally until the current sequester, are lobbying heavily to keep the cash cow going for outpatient cancer treatment.

Who would deny cancer patients their treatment?  I think that the same horrible people who deny gun control “for the children,” taxing the rich even more, or decry spending ourselves into oblivion ought to think about the big picture here.

Certainly cancer treatments that meaningfully offer a chance for cure and prolong a useful life are important.  Lance Armstrong offered a great example of a famous person cured of metastatic cancer.  We might blame some of his choices after the cure on chemo-brain, but that would be stretching it.

However, if you look at the meat and potatoes of how most chemotherapy providers make their money (and where most Medicare cancer dollars go), you will find that a whole lot of money is being spent that does little to improve the quality or quantity of life for most who receive it.  There are two types of cancer treatments:  curative and palliative.  I’m not going to touch palliative therapy in this discussion other than to say balancing quality of life of a patient and the insurance reimbursement you can squeeze out of treating a dying patient should not be but sadly can be an equation considered in most oncology out patient practices.

In my experience, most patients  embark on adjuvant treatment -an effort to cure an otherwise incurable cancer – with little understanding of the real odds they’ll derive any benefit from the treatment.  Sometimes they are goaded on by providers or family to “do something” when if they realized they had a 19 out of 20 chance of just getting sick and wasting a lot of time at the doctors, not to mention money, and still die when they would have without therapy, they might choose to not receive chemotherapy.

Adjuvant treatment for breast cancer for high-risk patients does reduce the risk of recurrence in about one fifth of patients treated. That means that 80% of women who receive third generation combined modality therapy either don’t need it or don’t benefit from it (if you define cure as your benefit).  Aromatase inhibitors can make life hell for patients with fibromyalgia-like symptoms, and they are “just hormone treatments” commonly used in Medicare-aged patients with about one out of seven benefit.

In colon cancer resected with involved lymph nodes the number of folks who benefit from adjuvant treatment is less, maybe about one out of eight in the highest risk groups.  Its much less for many who ultimately do choose therapy.

In lung cancer, about one out of twenty folks who receive adjuvant treatment after resection live significantly longer without recurrence.  Prolongation of life in those not cured is usually measured in one or two month intervals.

Yet in my experience, when cancer patients are offered adjuvant chemotherapy treatments, these are not the statistics they hear.  Usually its something like “we can reduce your risk of recurrence by 50%.”  BIG difference in emotional impact, same studies, same data.

I recommend that if we are going to re-up reimbursement for outpatient chemotherapy, we should demand that the patients hear the blunt published data regarding benefit from therapy versus no therapy in terms that describe the chances they have of meaningful benefit from the treatment (e.g., you have an 80% chance of not benefiting from this treatment), the expected short and long term side effects and quality of life, and that they have at least two days to ponder their decision before embarking on a treatment regimen.  I bet we’d get a significant reduction in Medicare costs for cancer treatment without reducing payment to providers.

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