Saturday, April 2

Doctors Profit from "Chemotherapy Concession"

Imagine sitting down with your doctor to receive the shocking news that you
have bone cancer and only a couple of years to live. Even worse, he tells you that your life expectancy will be considerably shorter unless you immediately begin an intensive round of chemotherapy.

Then imagine saying, "No thanks; no chemo for me," and going on to live for
well over a decade.

Against the odds, that's what happened to Michael Gearin-Tosh, a don of English literature at Oxford University. Mr. Gearin-Tosh's remarkable book, "Living Proof: A Medical Mutiny," in which he describes the rigorous nutritional regimen he used to control his cancer.

"Living Proof" is not an attack on chemotherapy use, but it offers a reminder that the need for chemotherapy should always be questioned because this harsh treatment is sometimes prescribed for cancers that simply don't respond to chemo. Why? The answer to that question uncovers a disturbing business aspect of chemotherapy that few patients ever get a glimpse of.

Offsetting costs

Cancer patients often receive chemotherapy drugs in the offices of their oncologists. This procedure, now fairly standard, was established in the early 90's to avoid the high costs of administering the drugs in a hospital. The wrinkle that makes this situation unique is that the oncologists purchase the drugs themselves and bill their patients. And the wrinkle that makes this situation a potential problem is that oncologists typically charge patients far higher amounts than they pay for the drugs. This practice is known as "chemotherapy concession."

The oncologists say they require the additional revenue from selling the drugs to offset the cost of special facilities and staff to administer the drugs. And because chemotherapy has become such a standard treatment, virtually all prescriptions for it are covered by insurance or Medicare, so the markups are generally not paid for by patients.

At face value, this would seem to be reasonable. But I'm sure you won't be surprised to find out there's much more to it than that.

Everyone pays

The problem with this "concession" system it that it perpetuates the use of chemotherapy - a problem that can be broken down into three distinct problems.

PROBLEM 1: Taxpayers are footing a large portion of the payout that goes to

According to the New York Times, the amount that the government pays may be more than $1 billion per year. That's $1 billion more than the actual cost of the drugs. This amount doesn't include the additional totals paid to doctors by insurance companies - totals for which there are no current estimates, although the chance is very good that the burden carried by insurance companies is at least equal to the amount carried by Medicare. And as we've often seen, when insurance claims rise, our insurance premiums follow.

The Times quotes Dr. Larry Norton, an oncologist and former president of the American society of Clinical Oncology, as saying that he and other doctors are just trying to "break even." Well, things are tough all over, but don't pass the hat just yet to help your local oncologist squeak by, because according the Medical Group Management Association, over the last ten years oncology has become one of the most lucrative fields of medical practice, largely due to the chemotherapy concession. By some estimates, two-thirds of a typical oncologist's total revenue comes from the concession.

Research suffers

PROBLEM 2: Because oncologists have a strong monetary incentive to prescribe
chemotherapy (after all, they're just "breaking even"), they are less likely to refer patients to clinical research exploring possible cancer cures and less abrasive therapies.

Natural Health Line recently interviewed Nicholas Gonzalez, M.D. - a clinical researcher who has treated cancer with nutrition for many years. When Dr. Gonzalez was recruiting patients for a federally funded study of a cancer treatment based on a nutrition regimen, enrollment in the trial was complicated by the fact that many oncologists were reluctant to refer patients and lose the revenue that the chemotherapy concession would bring.

Hard to justify

PROBLEM 3: The most important problem is the way chemotherapy concession affects the treatment of patients.

Two years ago, Ezekiel J. Emanuel, M.D. (an oncologist and bioethicist), presented the results of a study that examined the medical records of almost 8,000 cancer patients. Dr. Emanuel found that in cases where chemotherapy was administered in the final six months of life, ONE-THIRD of the patients suffered from cancers that are known to be unresponsive to chemotherapy!

In Dr. Emanuel's words, "providing chemotherapy to patients with unresponsive cancers is hard to justify."

I'd say that's putting it mildly.

Specific types of cancer that are not responsive to chemotherapy include: pancreatic, melanoma, hepatocellular, renal cell, and gallbladder. If you are diagnosed with one of these cancers and are prescribed chemotherapy, it's time for a second opinion.

1 comment:

Greg Pawelski said...

Screening tests may pick up minute tumors that would not progress and might even go away if left alone (pseudodisease). Patients will be alarmed and exposed, perhaps needlessly, to the risks of chemotherapy, surgery and radiation.

For some common cancers, it is not clear that early detection and treatment actually prolong patients' lives. Early detection may just mean patients spend a longer time knowing they have cancer, and yet die at the same time they would have died anyway if the tumor had been diagnosed later. A decision to forgo cancer screening can be a reasonable option.

Most of us think of cancer as a deadly disease if left untreated. But there are microscopic cancers that will never cause us problems. We all have abnormal cells, but most of us will not die from cancer. Pseudodisease is most common in prostate and breast cancer, and is an issue for kidney cancer, melanoma and lung cancer. When cancer is looked for early, a wide net is cast for both real and pseudodisease. Since we can't tell which is which, we treat it all. And for those who never needed treatment, treatment can only hurt.

Only 3% of men will die from prostate cancer (generally at a fairly advanced age). But pathology studies show that at least half of all men in their 60's have microscopic evidence of prostate cancer. Almost all men probably do as they age. If we look hard enough, we will find it.

Different pathologists looking at the same cells can reach different conclusions about who has cancer. This has been shown in prostate cancer, breast cancer and melanoma. There is no way to know who is right. Pathologists can readily distinguish between big invasive cancers and normal tissue, but they disagree about what to call cancer in a large gray area in between.

Seventy to eighty percent of breast cancer patients are given chemotherapy unnecessrily. And to those twenty to thirty percent who will have a recurrence within five years, it will only reduce the risk of cancer recurrence by 35 percent. Some tumors send out microscopic outposts, while others don't, so most breast cancer patients are given chemotherapy, just in case their tumors are the type that do. You put all cancer patients at risk dying from the treatment of cancer so some cancer patients who will get recurrence won't risk it not receiving adjunct treatment.

One must be objective and decide at what point the benefits of drugs truly outweigh the risks they present. Some of the risks are minor and others are tolerable in that they are reversible, short-term or non-life threatening. Many of the risks are extremely serious and are difficult to balance against relief from anything but the most severe symptoms. For some people the risks may be acceptable, for others, not.

Selling cancer chemotherapy with concessions creates conflicts of interest for oncologists