Delivering High Quality Cancer Care: Trend or Wishful Thinking?

A couple of days ago the Washington Post offered this “The best cancer care ins’t always the most expensive” written by Harold Pollack. The author takes a look at a recent report published by the Institute of Medicine (IMO) “Delivering high-quality cancer care: Charting a new course for a system in crisis.” His opening paragraph captures the report well…

Like many IOM publications, this report makes for depressing reading, not because it contains dramatic or frightening revelations, but because many of its recommendations are so obvious and yet would be so difficult to execute in our high-tech but unwieldy, costly and fragmented health-care delivery system.

Pollack summarizes the report well:

  • Too many patients having punishing and futile treatments
  • Costly imaging with little or no therapeutic benefit
  • Costly supportive care
  • Failure to use EHR
  • Fragmented care that drives miscommunication and errors

Cancer costs America 5% of the $2.8 billion healthcare economy and patients can benefit from more thoughtful and less toxic treatment when cure is not possible. Reading this I saw my film project “Care When There is No Cure“. And I thought of Donna and her care in the face of a Stage IV diagnosis for NSCLC. Donna was told she had 6 months. Her skilled and brilliant oncologist who I believe put care into healthcare told Donna when she asked him if she would die in 6 months “Not so fast”. He proceeded to create a course of therapy and care including a craniotomy that extended her life with excellent quality for nearly three years. I will say that the care Donna received looked like the chart below

I would take a look at the Washington Post article because there is an interview with Amy Berman who is a cancer patient diagnosed with Stage IV inflammatory breast cancer. She chose to receive palliative care three years ago. And her video is on the WP Web site as well as provided by the IMO. The video is excellent but, I must say the transcript from the discussion between Berman and Pollack is eye opening for its insight and candor. 

On the IOM Web site they have a complete list of items regarding this report from briefing slides, press release, questions patients ask, report brief, and videos. It is very complete resource for this important topic and issue. Did I say slide deck my fav format. The link to the deck is here.

The above slide is early in the deck but triggered my thoughts about communications, advertising, adult learning, and driving change. But the IOM speaks to the reality that  as a nation we will be facing this growing cancer crisis and not just in the prevalence of the disease but in the fact the crisis of how are we as HCP and caregivers are going to manage it and care for everyone. The fact is by 2022 30% of our aging population will have a cancer diagnosis. And consider the cost. By 2020 the cost of cancer care is anticipated to be $173 billion and increase of 39% from the $125 billion in 2010. And lest we consider just the toll on life there will be 18 million survivors of cancer by 2022. That number includes those less then a year to 15+ years. 

These are the report goals and clearly they will change the face of cancer care as we move forward. Each one is a task in and of itself with subsequent issues, problems, and outcomes. Following each of these goals are a listing of recommendations. I am struck not only by the reality of the list and recommendations but of the weight of each one to be started/implemented/accomplished either at the provider level or nationally. These are not small tasks nor are they all clinically driven.Which means can they be executed by the HCP alone or in a practice? Some of these are communications and educational. They are centered on the need to create programs, messages, tools, and more that is strategically driven and based on principles of education and marketing. Some of these are the soft arts not evidence based medicine or a p value. 

I question the ability of the medical and clinical community to drive the educational and communication goals they have laid out. Creating communications goals and aligned strategies are not easily achieved with measurable outcomes that meet and exceed the goals. What is needed are proven marketers who have shown success at driving HCP and patient change. In fact what is needed here are the very same people who convinced HCP to prescribe products that are only marginally more effective then placebo. And those very same experts got consumers to ask there HCP about treatments. Yes these are people who worked for the dark side but, they are the people who know communications and marketing. They are the people that know the science of medicine and can create strategies that change peoples opinions and drive action. And they are the people that providers tend to shun. 

Of course there are some sour grapes in my fruit basket and I will not deny that I must take responsibility for this but it strikes me that if we are to marshall a nation to know about and deliver high quality cancer care it should not be left to academics or clinicians alone. It requires all hands on deck and the talents and expertise of proven marketing and communications specialists with expertise not only clinical credentials. Whatever you think about those of us who worked for or are from the dark side we could drive a message, sell an idea, and get an Eskimo to buy ice cubes. The goals of IOM and cancer care will not be achieved quickly and easily. And will require disparate talents. 

Pain Management not Just a Global Issue

 It is well documented that patients with terminal illness in general do not receive what experts would consider appropriate and continuous pain relief. This is an issue even more acute globally. And the reasons are equally well documented: no access to morphine, HCP attitude, family concerns, lack of knowledge on how to treat.

On a very small scale and in many regards unrelated I witnessed this. Thursday I had to go to have a dental implant removed. It went from a scheduled procedure to an emergency one. I was able to contact my previous DDS who referred to a very good oral surgeon. Prior to him beginning I played 21 questions just to make sure I knew what was what. I asked about postoperative pain. “Do you have any ibuprofen at home?’ was his answer. After my WTF look and saying “you’ve got to be kidding me” he relented and said he would write a script.

The procedure was quick. I left the office with a ton of lidocaine on board. Not so bad. I got home laid down and within 30 minutes my face felt like I was hit with a brick. Acute, sharp, and relentless is how I would characterize the pain. Ibuprofen? In a pig’s eye? It would not even begin to touch this. Filled the Rx and found some relief behind the pain, not in front of it.

I will confess that within 24 hours the pain was resolved. Still, to feel like I needed to beg to get a strong analgesic that was in fact needed was a bit of an issue. This does not compare to chronic pain associated with terminal illness. I witnessed this with my wife in hospice and how well and professionally the pain management team kept ahead of her pain and was able, even when Donna could not communicate, to read her body language to know when they needed to change or increase medication. This was not the same. I do not expect an HCP who is board certified as a dental anesthesiologist and oral surgeon to understand pain and terminal illness. But he should know about pain and its effective management. Really now he should.

His first reaction was to not offer an analgesic unless asked. I was put into the role of a drug seeker. If I did not have that Rx I would’ve been on the phone demanding he call it in. Wasting his time and mine. At the very least he should describe the level of pain for how long and ask me what I thought I wanted. Not think he knew me better then he did at our first meeting. In some small small way this is the state of pain management.