When it comes to cancer care, there is a huge disconnect between the possibilities of modern medicine and its day-to-day practice. As last fall's troubling report from the Institute of Medicine noted, variation in oncology practice is wide; collection of quality and outcomes data is poor; and progress in learning what works best for any particular cancer remains slow and halting.
Where should you go for cancer care?
Even as providers in community and hospital settings work to improve the quality of care, advances in science tend to undermine those efforts. The marriage of low-cost gene sequencing technology and big-data analytics has tantalized patients confronting this life-threatening disease with the promise of personalized treatment plans that can achieve better results.
Yet the science is far from mature. It has generated only minor advances in the treatment of a few forms of cancer, and those advances have often come at substantial cost because of the high prices being charged for new drugs targeting specific genetic mutations.
Until personalized medicine generates the kind of results that begin to measure up to its promise, many insurers and clinicians will continue to move toward greater standardization of care as the surest path to better outcomes. Cancer care is complicated. There are often multiple options—surgery, radiation, chemotherapy—that can be offered in different patterns in different settings depending on the stage and severity of the illness.
The National Comprehensive Cancer Network, which includes most of the nation's cancer centers, routinely updates its algorithmic clinical practice guidelines for the more than 100 forms of cancer to accommodate the latest medical evidence. But, again, the rapid advance of scientific knowledge has turned that into a Sisyphean undertaking.
Every week, the global cancer research establishment, jointly funded in this country by the private sector and the National Cancer Institute, generates new clinical evidence. Many of those studies' findings, often involving treatments tailored to specific genetic variants of a cancer, suggest better outcomes can be achieved by deviating from what previously had been considered the preferred treatment guideline.
The ever-shifting medical science makes educating oncologists a daunting endeavor. The failure by some clinicians to adhere to the latest practice guidelines is the main reason why there is so much variation in care across the country. Indeed, setting aside the issue of inadequate access to cancer care because of a lack of insurance or cultural barriers, variation in care delivery is the single largest cause of the uneven results from cancer care.
Unfortunately, little is known about where that variation exists, why it happens and what it leads to. Though more than 60% of oncologists now have electronic health records, collecting that data and measuring the results from different practice patterns has only begun.
One question that needs answering is whether that variation is greater among oncologists working in a community practice, in a local hospital or a major cancer center such as M.D. Anderson or Memorial Sloan-Kettering. The answer isn't obvious.
The major cancer centers can certainly command a higher price because of their stellar reputations and marketing. But as we have seen in other practice areas such as cardiovascular care, high price and reputation aren't necessarily correlated with better outcomes.
The medical literature is missing solid studies comparing the quality and outcomes of care at competing cancer centers. Moreover, there are many confounding variables. Do the major cancer centers attract healthier patients because they are the ones who can travel? We know that when it comes to surgery, volume matters. Centers that do many surgeries tend to have better outcomes. But does that matter if you're the low-volume surgeon at a high-volume hospital?
Last week, a survey by the Associated Press found that insurers offering insurance plans on the exchanges were excluding some of the high-cost comprehensive cancer centers from their networks, presumably in an effort to hold down costs. There's no doubt that this is an absurd policy for some rare cancers, including most forms of pediatric cancer, which need to be treated at places that house those specialists.
But when it comes to the major forms of cancer that represent the bulk of the 1.6 million yearly diagnoses, the jury is still out on where patients can find the highest quality care at the lowest cost. Until we have solid data on outcomes from various care settings, discriminating by price is valid.
Follow Merrill Goozner on Twitter: @MHgoozner
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