Medicine and profits: an unwholesome alliance
“Oh Lord, lead me away from temptation… but not quite yet.
St. Augustine .
The New York Times in its May 9, 2007 issue, published a front page article about oncologists prescribing excessive amounts of anemia drugs to cancer patients on chemotherapy. The statistics are enlightening: the higher the “compensation” or monetary inducements offered to the oncologist-the higher the frequency and dosage prescribed. As they say on the TV commercial, “this drug is not for everyone”.
Inappropriate prescription can actually cause harm, and recent studies showed that inappropriately high doses result in increased mortality.
Response
The American Society of Clinical Oncology distributed a letter to the members.
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Complete Disclosure: I am a proud member of ASCO.
Response to the Response
· ASCO makes the same argument that professional people make when colleagues are caught with their hand in the cookie jar: most of us are conscientious, hard working people. Granted. But to turn a blind eye to the corrosive influence of pharmaceutical companies on the use of drugs is denial of the how our health care system “works” on a daily basis.
· ASCO is led by academic clinicians and researchers, whose motivation and dedication is admirable. But many of the rank and file, community practitioners, are not beyond temptation. Most so us aren’t, it’s just a question of ‘how much’. Indeed, the pharmaceutical companies spend more on ‘promotion’ and sales than they do on R&D.
· ASCO is a wonderful organization that promotes cancer research, education, and evidence-based clinical practice. I think it should keep its excellent reputation and avoid getting sullied by entangling itself in the sordid affair exposed by the New York Times.
· As an article in the New York Times of the next day ( May 10, 2007 ) showed, apparently no specialty of Medicine is immune from infectious mammon; psychiatrists are prescribing large amount of psychotropic drugs, many times inappropriately, to people who do not need them .
If the New York Times is going to continue with this series, the next specialties to come into the harsh light being shined on Medicine may be cardiology, orthopedics and radiology. The abuses in these specialties are a well-known secret in the medical community.
As the wheels are coming off our broken health care system, more revelations of waste, abuse, greed and outright criminality are bound to surface. What are we going to do about it?
Dov Michaeli MD, Ph.D
The Doctor Weighs In
in ASCO, America society of Clinical Oncology, Cancer, Dov Michaeli, Health care costs, Healthcare quality, Medical care
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Here is the first post of new TDWI writer, Brian Klepper, PhD -- a different kind of doctor, true, but one who knows the health care industry inside and out.� Dr. Klepper is the Founding Director of the Center for Practical Health Reform, a broad-based n
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How about published reports of clinical trials?
More chemotherapy is given for breast cancer than for any other form of cancer and there have been more published reports of clinical trials for breast cancer than for any other form of cancer.
According to NCI's official cancer information website on "state of the art" chemotherapy for recurrent or metastatic breast cancer, it is unclear whether single-agent chemotherapy or combination chemotherapy is preferable for first-line treatment. At this time, no data support the superiority of any particular regimen. So, it would appear that published reports of clinical trials provide precious little in the way of guidance (1).
In the total absence of guidance from published reports of clinical trials then, what basis are treatment regimens selected instead? ASCO says that this should be further based on a patient's health status and patient treatment preferences.
So what is being done?
Recently published in the journal Health Affairs is a joint Harvard/Michigan study entitled, "Does reimbursement influence chemotherapy treatment for cancer patients?" The authors documented a clear association between reimbursement to the oncologists for the chemotherapy of breast, lung, and colorectal cancer and the regimens which the oncologists selected for the patients. In other words, oncologists tended to base their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist (2).
A March 8, 2006 New York Times article described the study. One of the more interesting aspects of the story was a comment from an executive with ASCO, Dr. Joseph S. Bailes, who disputed the study's findings, saying that cancer doctors select treatments only on the basis of clinical evidence (3).
So ASCO's Dr. Bailes maintains that drugs are chosen only on the basis of "clinical evidence."
Yet, Dr. Neil Love reported in a survey of breast cancer oncologists based in academic medical centers and community based, private practice medical oncologists. The former oncologists do not derive personal profit from the administration of infusion chemotherapy, the latter oncologists do derive personal profit from infusion chemotherapy, while deriving no profit from prescribing oral-dosed chemotherapy.
The results of the survey could not have been more clear-cut. For first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists (who are motivated to keep off-protocol patients out of their chemotherapy infusion rooms to reserve these rooms for on-protocol patients) prescribed an oral-dose drug (capecitabine), while only 13% prescribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel.
In contrast, among the commuity-based oncologists, only 18% prescribed the non-remunerative oral-dose drug (capecitabine), while 75% prescribed remunerative infusion drugs, and about 40% prescribed the expensive, highly remunerative drug docetaxel (4).
There are patients who have progressive disease after first-line therapy, only to enjoy a dramatic benefit from second or even third line therapy, and these patients would have been much better served by receiving the most probable active treatment "the first time around."
While being faced with a large number of choices of otherwise equally acceptable therapies, oncologists select the treatments which generate the most income for private practices or generate the least inconvenience for the clinical research institutions.
What needs to be done is to remove the profit incentive from the choice of chemotherapy treatments. Medical oncologists should be taken out of the retail pharmacy business and let them be doctors again.
Sources:
(1) http://www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page8#Section 297
(2) http://content.healthaffairs.org/cgi/content/abstract/25/2/437
(3) http://www.nytimes.com/2006/03/08/health/08docs.html?ex=1145160000&en=584b5c2aa35995a3&ei=5070
(4) http://patternsofcare.com/2005/1/editor.htm (figure 37, volume 2, issue 1, 2005)