Chemotherapy and Breast Cancer – Good or Bad?

 

The pendulum is swinging back. Years ago chemotherapy for breast cancer was rare. Later, it seemed everyone received it. Now some are questioning that routine.

When I was a young surgeon in training I did mastectomies for women with breast cancer. Those who had no evidence of metastasis (spread of the cancer) received no other treatment. Those with metastasis received radiation therapy and sometimes chemotherapy.

As experience with chemotherapy increased and new drugs were developed, more chemotherapy was given. Many women with no evidence of metastasis still received chemotherapy after surgery. Today that practice is being re-evaluated.

Lucette Lagnado, writing in The Wall Street Journal, says the shift to less chemotherapy is being called “de-escalation.” Proponents of this shift believe many women have been overtreated with drugs that may have harmed more than helped. They believe chemotherapy should be reserved for those women who have a high risk of the cancer spreading.

Oncologists Differ

This de-escalation has created a rift between those oncologists who support this trend and those who do not. Cancer mortality rates have improved since the late 1980s and some researchers credit chemotherapy for this improvement. Although chemotherapy agents have been in use since the 1940s, current drugs are less toxic than the early days when nitrogen mustard was used. Side effects are less and ways to diminish their impacts on the patients have improved.

Dr. Steven Katz, a professor medicine at the University of Michigan, is a supporter of de-escalation. He says, “Tens of thousands of women were overtreated; they got surgery they didn’t need, they got radiation they didn’t need, and they got chemotherapy they didn’t need.”

Today patients are routinely given genomic testing to determine the behavior of their tumors. A low score means a woman has a good prognosis and won’t benefit from chemotherapy. A high score means a greater risk of recurrence and a need for chemotherapy. A middle score presents the greatest treatment decision challenge.

Katz and Stanford oncologist Allison Kurian published a study in the Journal of the National Cancer Institute. The study was composed of about 3,000 women with early-stage breast cancer treated by some 500 doctors from 2013 to 2015. The study revealed that the use of chemotherapy declined overall during that time from 34.5% of cases to 21.3%.

Other doctors are more skeptical. At New York’s Memorial Sloan Kettering Cancer Center, Dr. Jose Baselga says that while there is data to support forgoing chemotherapy on certain women with early-stage disease – and he had personally been prescribing less – these represent only a small fraction of patients. He believes others will die if chemotherapy isn’t given.

Another study published in The New England Journal of Medicine in 2015 looked at the treatment of over 10,000 women. Of these, 1,626 had early-stage breast cancer with no lymph node involvement. They were given hormonal treatment alone, without chemotherapy. Those with a low genomic test score had “very low rates of recurrence at five years with endocrine therapy alone.”

But others warn of their experience in the past. Dr. Gabriel Hortobagyi, has practiced oncology for over four decades at MD Anderson Cancer Center in Houston. He recalls the years when high percentages of women died from breast cancer. He credits chemotherapy for helping achieve the turnaround we enjoy today. He believes chemotherapy has saved “tens of thousands, maybe hundreds of thousands of lives.” But he stresses, “We have to do it responsibly and on the basis of the highest level of evidence. The worst toxicity is death.”

 

Technologic Innovations Impact Healthcare

 

Technology is changing our world. Healthcare is no exception.

Andrew Arnold writes in Forbes of four technological innovations that are having an impact on our healthcare. He makes the following statements:

  • Cloud electronic records improve access to health information
  • Telemedicine is becoming more accessible
  • Big data and artificial intelligence usage is going mainstream
  • IoT devices and robots will improve the care quality

 

Cloud electronic records

Electronic medical records have largely taken over most hospitals and many physician offices after strong arm-twisting by the Obama administration. Those hospitals and physicians who refused to make the switch are paying now in the form of deductions of their Medicare payments.

While most of these institutions maintain their own records in house, a growing number are relying on cloud technology to provide storage. Arnold says the use of cloud technology for storage has two benefits:

  • Patients can access their own records by using passwords or key codes
  • Multiple providers can access individual patient records – by sharing the passwords or key codes. He believes a national database of medical records is the next logical step.

 

Telemedicine

Arnold says millenials want much more control over their health and the care they receive. Furthermore, he says they are impatient by nature and don’t want to be bothered with ancient concepts like “making doctors’ appointments and getting treatment for what are non-serious conditions/illnesses. They prefer internet-based visits on their own time.”

He believes the solution is more telemedicine. Furthermore, this will improve healthcare in rural areas where fewer specialists are available. The use of video monitors may make it easier to have a conference with other physicians at the patient’s bedside. This may save lives in poorly served areas.

Bid Data and Artificial Intelligence

Pooling of data from sources all over the world will lead to improved diagnostic accuracy and treatment. He says:

  • Providers can use data to develop better patient profiles and risk factors.
  • Computers can predict the future effectiveness of treatment by analyzing data of past successes and failures.
  • Reduction in provider costs – by predicting re-admission rates of patients and times of months and year of high and low demand. This will lead to lowered provider costs and presumed lower healthcare spending.

 

IoT Devices and Robots

This refers to devices worn by patients that monitor heart rates, blood pressure and blood sugar levels. Electronic stethoscopes and goniometers are now available in educational institutions. Arnold says this will lead to savings by reducing costly office visits that will no longer be necessary or alert providers to conditions that warrant immediate care and treatment.

Robotics such as the DaVinci surgical tool are currently in use for those procedures that demand greater precision through smaller incisions – such as brain and prostate surgery. Arnold sees robots providing many of the activities of nurse’s aids.

Count Me Skeptical

All of the above sounds great from the perspective of the outside world (those not providing healthcare). But as one who has been a physician providing care for the last 43 years (including training), I have a few concerns:

  • Electronic medical records – These were supposed to revolutionize medicine and eliminate medical errors, reduce employee staffing, improve efficiency, promote communication across distance barriers, and reduce costs. None of these expectations have been fully realized. (For more on this see Electronic Health Records – Another Obama Train Wreck.)
    • Cloud storage may be a method of improved storage and facilitated recovery of information from remote locations. However, security has not lived up to the promises given and increased access by more people will only increase this problem.
  • Telemedicine – This is no substitute for a “hands on” examination and “face to face” conference with your doctor. Millenials may be impatient but they will pay a price in lowered quality healthcare if they try to get their healthcare online without establishing a proper patient-doctor relationship. (For more on this see Beware Online Medical Treatment.)
    • Telemedicine does make sense for remote areas of the world where there is no other alternative.
  • Big Data and AI – Certainly we should use increased data analysis to improve our understanding of disease processes and treatment outcomes. Orthopedics has been leading the way in this area for years with registries for outcomes in total joint replacement worldwide.
    • Reduction in Provider Costs – Don’t expect any savings by the hospitals to be passed on to consumers. They are not building bigger and fancier buildings by returning savings to those who pay the bills.
  • IoT Devices and Robots – These devices may improve our ability to monitor our health (or our disease) better and may lead to improvements in treatment and recognition of emerging health crises. However, don’t count me excited to think that a robot will replace the human touch when it comes to nursing, even for nurse’s aides.

 

Arnold is certainly correct when he warns there is a risk with all this new technology. He says, “But with all of this promise comes a huge risk – security. And technology has had a hard time keeping up with the cybercriminals who are quite adept – just ask Experian or the IRS. A potential solution lies in blockchain technology, and some healthcare providers are already experimenting with it.”

I’m sure the cybercriminals will find a way to figure that one out, too.

Do Doctors Waste Healthcare Dollars?

 

Which would you prefer; overtreatment or undertreatment? That’s the fundamental question behind a recent Harvard study.

Peter Ubel, writing in Forbes, tells us that American physicians dole out lots of unnecessary medical care to their patients. He says they prescribe unnecessary antibiotics for people with viral infections, order expensive CT scans and MRIs for patients with “transitory back pain”, and obtain screening EKGs for people with no signs or symptoms of heart disease.

Several allegations have been made against doctors to explain this:

  • More tests and treatment are ordered for private (wealthier) patients than for those on Medicaid and those without insurance.
  • Physicians order unnecessary tests and treatment to bolster their incomes.
  • Physicians order fewer tests and treatment for people who cannot pay.

 

A Harvard study recently tested these hypotheses. Michael Barnett and his colleagues researched how often patients received “unnecessary services.” They compared patients with private insurance to those with Medicaid and also those without any insurance.

Study Results

The results may surprise you. They certainly surprised Peter Ubel. Here is a summary:

  • Almost 20% of private insurance patients receive “unnecessary services.”
  • Almost 20% of Medicaid patients receive “unnecessary services.”
  • Almost 20% of the uninsured receive “unnecessary services.”

In other words, doctors treat people the same regardless of their type of insurance – or lack of insurance! Would we want it any other way?

Ubel believes this is disturbing because he says, “In short, there’s way too much wasteful care, regardless of what kind of insurance people have or don’t have.”

The study did note some variations in the type of “unnecessary services” received by insurance coverage. Private insured and Medicaid patients received “unnecessary antibiotics” for respiratory infections about half the time while this happened to three-quarters of the uninsured. Narcotics were prescribed for back and neck pain more often for the uninsured (almost 50%) but only 33% for Medicaid and 25% for private insurance.

Ubel, who is an academic physician at Duke University, guesses at explanations for these findings:

  • When ordering tests like EKGs, physicians operate “out of habit.”
  • Patients are “powerless” and don’t push back when doctors order “unnecessary services.”
  • Contingency antibiotics – they order these more often for patients they don’t know (and can’t rely on to return) than well-established patients
  • Narcotic insanity – he has no idea how to explain these findings
  • There is no evidence of physician greed in these findings.

 

Ubel says he would be eager to hear the thoughts of clinicians who care for these populations to hear their explanations. Here are mine:

  • “Unnecessary services” is very subjective and good doctors can easily disagree on what is unnecessary.
  • Most “unnecessary services” are ordered out of an abundance of caution to avoid unnecessary complications. Would you rather have undertreatment?
  • Our litigious culture demands doctors protect themselves from malpractice claims by an abundance of caution. No one is suited for overtreatment or too many tests.
  • While overtreatment may increase costs and have deleterious effects on the nation as a whole, it rarely adversely affects individual patients. Unnecessary antibiotics do lead to antibiotic-resistant organisms.
  • The uninsured usually represent a more transient, sicker population that warrants overtreatment when follow-up is unreliable.
  • Patients are not powerless. If they can’t afford treatment or tests they usually don’t get them.
  • Medicaid patients and the uninsured generally demand narcotics more often than the privately insured population. Both populations are frequented by those who abuse narcotics or sell them or both. (see Medicaid and the Opioid Crisis Medicaid and the Killer Drugs)

 

Hospital Waste

Wasteful healthcare spending is more of a problem when considering the difference between private physicians and those who are employed by hospitals. There is an alarming trend toward hospitals acquiring private physician practices because they can charge more for the same services. These physicians are often subjected to quotas that incentivize their treatment decisions.

Therefore, it is no surprise to me that Mr. Ubel also references another study in the Journal of the American Medical Association Internal Medicine that drew the following conclusions:

“Visits to US hospital-based practices are associated with greater use of low-value computed tomography and magnetic resonance imaging, radiographs, and specialty referrals than visits to community-based practices, and visits to hospital-owned community-based practices had more specialty referrals than visits to physician-owned community-based practices. These findings raise concerns about the provision of low-value care (unnecessary) at hospital-associated primary care practices.