As I write this blog on a lazy Sunday afternoon a monsoon is raging outside, so outdoor activities will be somewhat limited today. But it is nice to take a break after a busy week.
We had two bittersweet goodbyes last week. Mia Caparas is leaving the area to pursue a Pharm.D. Degree at Fairleigh Dickinson University in New Jersey. Thanks, Mia, for all you have done. And, Dr. Andrew Putnam is leaving MGUH for Yale University. “Put’ has been the face of palliative care for Lombardi’s patients for some time, and we will miss him. I wish him well in his new endeavors.
My Thursday afternoon clinic was quite busy, with three new patients, and a number of follow-up patients as well. One of the new patients has metastatic pancreatic cancer that progressed when he was treated with gemcitabine, which has been the single-agent standard of care since it was approved in 1996 based upon a less than 10% objective response rate, a minor improvement of quality of life and average survival of six months. When his disease worsened his oncologist added the oral agent capecitabine, a fluoropyrimidine with nearly no single-agent activity in this disease, and no documented utility in combination with gemcitabine in this clinical setting. I don’t blame the oncologist, who was merely trying to help his patient, but this vignette neatly capsulizes one of the major challenges we face in the field of health care.
How can we possibly afford to take care of people when they are able to receive expensive, largely ineffective therapies? And, how can we make progress when more than 95% of all cancer patients receive all their treatments outside the context of clinical trials that can identify newer, better treatment approaches? Surely, there must be a better way.
I do not believe the answer lies in restrictive rationing. This approach flies against the unspoken contract that doctors have with patients in our society – that we will do what is best for the individual patient – essentially, that people matter. The potential violation of this “contract” by certain elements of recent health care reform efforts struck a chord with many Americans, and created ideological polarization that precludes respectful and thoughtful dialogue. Sadly, this has interfered with the obvious opportunities we have to do what is right for each individual by practicing true evidence-based medicine. For example, there is no evidence that any so-called second-line therapy composed entirely of currently standard agents has utility in metastatic pancreatic cancer. However, this is a great opportunity to test new agents and therapeutic concepts in clinical trials that might actually make a difference in the lives of these patients and those who will follow.
In a very real way, this approach puts the patient first by sparing the toxicity, inconvenience, wasted hopes and expense of therapies that are doomed to fail. Since the incremental cost of conducting such trials is typically borne by pharmaceutical company sponsors that will benefit from approval of their drugs, the cost of care to the public is reduced, and conditions for innovation and progress are incentivized. Now, imagine the impact if these principles were applied to other cancers, and indeed to other diseases.
Much of what we do is well intentioned but misguided. If we just put the patient first, and do so with a clear-eyed understanding of how effective our interventions are likely to be, we can reduce the cost of care and accelerate progress. This is but one element of a much larger and complex puzzle, and this is just my personal opinion. The Medical Center is putting together a working group to examine this and many other questions related to the important issue of health care reform — what an interesting discussion that will be.
Meanwhile, I plan to do my part by screening this patient for participation in clinical trials for which he might be eligible. I will let you know how it turns out.
My coming week will be highlighted by a Strategic Planning exercise that will involve many of Lombardi’s leaders, and by preparations for our September 11 External Advisory Committee meeting. I hope you have a good week, even if you are not on vacation!