Buyer beware

A patient of mine returned from being evaluated at famous clinic in this country.  I would consider this clinic as a alternative medicine clinic.  The recommendations that were given to this patient for therapy really angered me. There is a great difference between practicing oncology based on scientific evidence and practicing oncology based on what sounds good or may seem exciting & trendy.  So many times patients return from tertiary care facilities, or alternative care clinics with recommendations for treatment that have no scientific basis.  This leaves local oncologists to try to:

1) Get patients insurance companies to approve these medicines

2) Leaves these local oncologists in the situation of trying to explain to patients why the so called “leaders in the country” are recommending unproven therapies.

 This is a very difficult situation for an oncologist to try to deal with.  Patients want the latest and greatest therapies, but what patients don’t understand is that many times these new drugs, or new combinations that are recommended are found later not to be effective.  They end up, when fully evaluated, to be found to have higher toxicity with no greater chance for cure or survival.

 There is a movement in the United States to try to treat patients based on the best possible combination of medications. Making recommendations based on the most recent data available in the scientific literature. This is called evidence based medicine.  The NCCN and the American Society of Clinical Oncology have published practiced guidelines or “pathways”.  These pathways are made by the experts in a particular area of oncology. For example, breast cancer guidelines being drawn up by experts in the treatment of breast cancer.  The experts take the best available evidence and put it in a comprehensive pathway that recommends initial work up, diagnosis and then treatment of particular subtypes of cancers.  What angers me about tertiary care facilities, such as, MD Anderson, Mayo Clinic, and others is that many times patients return from these institutions given recommendations that fall outside these institutes own published guidelines.  It seems like these institutions believe that patients coming to see them want the newest, latest, greatest medicine even though the newest, latest, greatest combination of medicines may be unproven and have a higher risk of toxicity. There have been many times in oncology, where things that have seemed like a good idea, have become the standard of care, then only to have additional studies ultimately show these therapies to be no better, if not worse, than this standard of care.  Examples of this are stem cell transplant in breast cancer, the drug Iressa, and most recently Procrit like drugs where data suggests that use of these drugs may, in fact, increase mortality.

 I always tell patients that are going to a referral cancer center to ask hard questions of the doctors that they see, questions like “has the therapy you’re recommending been proven to be better than the standard of care?”, “what are the extra toxicities associated with new combinations?”, “will my insurance company pay for it?”.  It is so easy for these centers to make these recommendations knowing that they don’t have to worry about the possible complications and trying to get chemotherapy covered by insurance.

I encourage all my patients to get a second opinion. If they have any questions about their therapies, I believe that second opinions ultimately make the patient a better patient.  But when patients seek a second opinion, I try to educate my patients on how get the most out of the second opinion. This requires some work on the patient’s part.  I believe they need the following: 

1) They need to have as much information about their disease as possible, either from the internet or other sources.

2) They need to write down a list of specific questions that they want a second opinion to answer.

3) They have to be ready to ask hard questions, such as, “what is the cost, what is the toxicity, why is the regimen that you’re recommending better than the standard of care and how has that been proven?”

 By asking these questions, they can truly evaluate whether the recommendations that they are getting are superior to the recommendations that they have received from their local oncologist.