A few weeks ago, I had just come home from work when I heard a soft knock at my apartment door. I asked “who’s there?” and could barely hear a very small voice replying.
I opened the door and saw a tiny woman: skeletally thin, bald– just a few tufts of dark hair standing up on a bruised skull. Her dark eyes were enormous. After a second of shock, I recognized her as my long-time neighbor, Anne.
I don’t know her well, but by instinct, I put my arms around her and tried to hold her.
She pulled back: “Please don’t,” she said, and she began to cry. “I’m so very sick. I hurt everywhere. It hurts when you touch me. I even screamed at Alan on the street,” she said referring to her husband, “when he tried to pat my back.”
I knew that Anne had suffered from cancer some years ago, and recently, I had heard that it had come back. A neighbor had told me that she was staying with friends in New Jersey while undergoing another round of chemo.
Now she has come home. I believe that she has come home to die.
She has come to me because her husband isn’t home (they separated before the cancer came back), and she can’t get into her apartment. She has two keys for the two locks to her front door and isn’t able to figure out how to use them.
She is apologetic: “The chemo does things to your mind,” she says.
Then she adds, “I’m sorry, I can’t remember your name. But I know you wrote a wonderful book.”
I explain that the fact she doesn’t remember my name doesn’t matter. That she remembered the book is so very kind. “To me, that matters more,” I tell her.
I see the shadow of a smile. She has always been a very gracious woman, and at this moment, she realizes that, despite all of the pain, she still possesses the power to make others feel good.
When we get to her apartment, I open the locks. She won’t let me in—“The apartment is a mess,” she says. “And I just want to lie down.”
I understand that she wants to be alone. I persuade her to give me a piece of paper and write my phone number down, in case she needs something or someone during the night.
I don’t expect to hear from her. And I didn’t.
But I do find out that her husband is coming every day to visit her and bring her things she needs. I still think she has come home to die.
And I also believe that the chemo that was supposed to help her may have done her more harm than good. Of course, I don’t know for sure.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
A few days after Anne came to my door I opened the newest issue of JAMA
to find this story: “The Role of Chemotherapy at the End of Life: When
Is Enough, Enough?"
The authors, Doctors Sarah Elizabeth Harrington and Thomas J. Smith,
begin by acknowledging that as chemotherapy becomes more available—and
better tolerated—“its use at life’s end involves a sophisticated
assessment.” The physician needs to focus on the patient’s goals while
simultaneously trying judge whether the treatment will do any good.
Ultimately, Harrington and Smith observe, physicians find themselves
making “judgments about the use…of costly resources despite little
chance of benefit."
Are Americans ready to deny chemotherapy to patients who appear close
to death on the grounds that it just isn’t cost-effective?
I think there is a better answer.
Palliative Chemotherapy
Begin with the facts. Harrington and Smith, who are both researchers
at the Virginia Commonwealth University Massey Cancer Center, report
that today, more and more dying patients receive “palliative
chemotherapy.” Palliative chemotherapy is not meant to cure. Indeed,
the authors point out: “Chemotherapy for metastatic solid tumors such
as lung, breast, colon, or prostate cancer rarely if ever cures
patients. The indication for such chemotherapy is to improve
disease-free or overall survival, relieve symptoms, and improve quality
of life.”
Just how many dying patients receive chemotherapy? One study reveals
that more than 20% of Medicare patients suffering from metastatic
cancer started a new chemotherapy treatment regimen in the 2 weeks
before they died. Another study shows that “in one community practice,
40 percent of lung cancer patients were given chemo within 30 days of
death while another 20 percent received chemo within 14 days of dying.”
Finally, in 2008, a medical director of a large insurance company
reported that 16% of its cancer patients receive chemotherapy within
two weeks of dying.
Given the rarity of “curable cancer,” palliative chemotherapy accounts
for “most of the work of everyday oncology,” the authors report. This
raises the obvious question: at what point is such treatment futile?
Just how much benefit should a physician expect in order to justify not
only the cost, but the physical suffering and memory loss that can
accompany treatment?
Here, we’re told, “The American Society of Clinical Oncology [has not
been able to] decide on a minimal benefit for which chemotherapy was
indicated, only that some benefit must be demonstrable.”
Some oncologists believe that too many of their colleagues encourage
patients to undergo “another round” of chemo. “From where I sit, the
problem is clearly one of perverse [financial] incentives which reward
guys like me for giving folks lots of chemo—whether or not it will
likely help them and whether or not they really understand the
implications of their decision to have it,” says Dr. Peter Eisenberg,
an oncologist in Marin County, California.
"As a board member of the American Society of Clinical Oncologists, I
have tried to get our professional organization to be more active in
this area," Eisenberg adds. "Unfortunately, they are a trade
organization and have not yet been very active. So I’m speaking for
‘Pete,’ not for the board."
In his own practice, Eisenberg says he does not urge patients to
continue chemo unless he is quite sure it will help them.“Most
oncologists don’t talk about the important stuff,” he confides. “They
just say, ‘In six to eight months, if this doesn’t work, we’ll try Plan
B’…
“I ask my patients: ‘How do you want to spend the rest of your
foreshortened life? Do you want to spend it hanging out with me and my
staff—or do you have something else that you want to do? I know I can
make you sick. I’m not at all sure I can make you better.’”
There is even some evidence that, rather than prolonging life, chemo
can shorten it. Harrington and Smith point to a “large study of matched
patients who received hospice and no chemotherapy versus those who did
not receive hospice care but had chemotherapy. The study showed that
survival was significantly longer for hospice patients with lung cancer
and pancreatic cancer, marginally longer for colon cancer, but no
different with breast or prostate cancer.”
Why Do patients Receive Chemo Just Days Before Dying?
Nevertheless, many patients see another round of chemo as their last hope.
Harrington and Smith use a case study to illustrate the problem. “In
April of 2005, Mr. L., a previously healthy 56-year-old businessman”
went to his doctor complaining of progressive back pain. A biopsy
revealed lung cancer that had spread into his vertebrae and his brain.
Mr. L was a fighter: “He wanted to survive his lung cancer at all
costs. He lived 14 months with 3 types of chemotherapy, receiving
chemotherapy just 6 days before his death.”
Did Mr. L. receive too much chemo? To answer the question “When is
enough enough?” one needs to consider the quality of his life during
those 14 months.
Initially, Mr. L. tolerated his treatment quite well, and for 4 months
his cancer did not grow. Then the disease began to progress, and he
switched to a new medication which kept the cancer from growing for
another four months. During this period, he was able to travel and
lead a normal life. However, in January 2006, Mr. L’s tumor began to
grow again.
By March, Mr. L. needed a wheelchair and had become incontinent. His
doctor started him on a new twice weekly treatment. He improved
slightly then remained stable for 4 months. He was well enough to
return to work part-time and to travel a bit. But soon the tumor began
growing.
“Mr. L. continued to want active therapy,” Smith and Harrington
report. “He attempted to enter a clinical trial for an investigational
central nervous system chemotherapeutic treatment, but was not accepted
due to his general debility.
After several falls, Mr. L was back in his wheelchair. In July 2006,
he developed pneumonia and was admitted to the hospital. At this point,
he needed nasal oxygen to help him breathe; cranial palsy had left him
with a facial droop; his voice was hoarse, he no longer had a gag
reflex and his breathing was so labored that he made “coarse breathing
sounds.” By now, his oncologist had suggested that he switch to hospice
care. But Mr. L. refused. He wanted to continue fighting the disease.
He wanted more chemo.
The medical house staff called in a palliative care specialist—someone
who is trained to help dying patients consider their options. (See my
recent post on palliative care here). The
specialist, who Harrington and Smith call “Dr A,” discussed Mr. L. with
his oncologist who now estimated that the patient had "only a month to
live." Dr A estimated that Mr. L. might only have 2 weeks left.
Dr A recalls that he then talked to Mr. L’s son, who was a medical
student, and his sister, who was visiting from abroad. “They were
shocked about the prognosis that I offered…of days to weeks. They were
still expecting more chemotherapy. Here I was, walking into the room
and basically saying, ‘Okay, folks, it’s time for hospice.’"
But after this meeting, everyone acknowledged that this was the end of
beneficial palliative chemotherapy. Mr. L’s oncologist was no longer
recommending chemo. The family accepted the doctors’ advice.
The palliative care specialist then met with Mr. L and his wife, who
also agreed to their recommendations. Mr. L. was transferred to his
home, where he received hospice care. He remained alert and interactive
for several days. On the sixth day at home, Mr. L died peacefully with
his wife and his children at his side and with his favorite music
playing.
Mr. L’s wife was happy with the care her husband had received: “our
oncologist this case was amazing…He obviously knew what the outcome was
going to be, but you always pray for the miracle. I think the miracle
we got was another year of his life…
“You know, my husband was extremely determined to remain positive, and
he never was going to give in [to the fact] that this could eventually
kill him,” Mrs. L. continued. “It didn’t really dawn on my husband that
he was going to die until he was in the hospital with pneumonia, which
was 2 weeks before he passed away…I think my husband lived very well at
the end and he died well.”
Thanks to the chemo, Mr. L. did enjoy at least eight months of
high-quality life following his diagnosis.
But what about the final six
months?
Smith and Harrington report, “the admitting house staff and palliative
care consultant had a sense that [since the cancer had spread to Mr.
L’s brain], he was not always making informed choices and had lost
opportunities to do other important things with his remaining time
while pursuing further chemotherapies and clinical trials. They had
concerns about providing care (such as the final dose of chemotherapy
six days before his death) that really could not help the patient.”
Dr. A, the palliative care specialist, also believed that the family
and patient were unprepared for the nearness of death, and that he
should have been called in earlier.
To be fair to Mr. L’s oncologist, it is often extremely difficult to
estimate how much time a patient has left. A recent study
of 196
physicians caring for 70 patients who died in the hospital shows that
when the patients were admitted, 86 percent of the physicians were not
at all certain as to whether the patient would die during that
hospitalization. The study, which was published in the Journal of
Palliative Medicine, shows that over the course of the hospitalization
86 percent reported knowing death was imminent. But most reported
certainty only days (57 percent) or hours (18 percent) before the
patient died.
Yet even though Mr. L’s oncologist couldn’t know when Mr. L. would die,
he knew that eventually, the cancer would kill him. There was no hope
of a “miracle.” And if he had said as much to Mr. L, his patient might
have been quicker to recognize that, in the final months he had left,
11th hour treatments were not going to save him. Smith and Harrington
elaborate: “Mr L’s palliative care specialist noted that because
patients are vulnerable to fastening on slim hopes, oncologists must
improve their skills in helping patients think clearly about the
appropriateness of chemotherapy.”
Mr. L’s oncologist explained that he did his best. Just a few weeks
before he died, “Mr. L was still in a ‘I’ve got to do something’ mode,
but I was telling him . . . . ‘We’ve got to get hospice going so that
you can relax and everyone [in your family] can get what they need and
they can move on.’ He was not having any of it, though. . . I couldn’t
get him to stop thinking that he needed one more treatment. One more
treatment was what he needed to spring him loose.”
And in truth, Mr. L’s oncologist couldn’t force Mr. L. to accept hospice care.
But should the oncologist have refused to continue giving Mr. L. chemotherapy?
In part 2 of this post, I will talk about how Mr.L’s oncologist might
have helped him, alternatives to “just saying no” to the patient,
“honesty and hope”, and the cost of trying to deny death.
Maggie;
THANKS!
I am absolutely convinced that this is the very issue around which our health care system and for that matter,our nation, can finally mature.
Dr. Rick Lippin
Southampton, Pa
One would ask, “Who is the customer of a medical oncologist’s services?” You might think the patient. True enough. But oncology is also a referral specialty. Medical oncologists have to be good doctors, who provide good services, or they will lose their referrals to medical oncologists who provide better services.
Eisenberg, in an appearance on NBC a couple of years ago, was correct in saying that there are conflicts of interest wherever self-referral rears its ugly head. Surgeons are one of the most notorious self-referrers on the planet, but it’s hard to figure out how to correct this.
A surgeon can spend five minutes telling a patient he needs an operation and a half hour doing the operation and then have three 5 minute post-op care sessions and make thousands of dollars.
Or the surgeon can spend the same amount of time in non-surgical examination, work-up, explanations, and ongoing care and essentially make peanuts. There are more neurosurgeons in Boston than there are in all of England.
Over the last 20 years, there has been a lot more per capita abuse of chemotherapy than of surgical oncology, in terms of cost benefit ratio to the system and toxicity benefit ratio to the patient.
It’s up to people who post and reply on this blog to make a difference by speaking out, in fixing those aspects of all of this which have gotten broken along the way. If medical oncologists were paid for their thinking skills rather than for selling medications, the use of drugs may fall.
Everybody is different.
The situation of a senior wiped out by chemotherapy, knowing they’ve lived a long and good life if different from that of a 35 y/o with young children or a 55 y/o with a satisfying job and grown children.
I think people’s lives would be happier if they focused on improving the end-of-life quality, but it isn’t for any of us to tell someone that it’s over.
Maggie, Thanks for giving voice to this realm of health care practice and policy, and to this realm of living and dying in the U.S..
The issues you touch on are some of the reasons why I left oncology nursing 15 years ago and why I have chosen to devote much of my life to health system reform activism.
Health care must be centered on people and their human needs, not on profits, if we are to be able to focus on what’s good for the person and their family…
Thank you again.
Anne, Ginger, Gregory and Dr. Rick–
Thank you all for your comments.
Anne–I hadn’t known that you were an oncology nurse, but that makes sense.
You’ve seen the patients who most need care and comfort–even if they can’t be cured. And too often, our system fails them.
Little wonder that you have become a health care advocate.
Ginger–
I agree completely.
When my children were young, if I had been diagnosed with cancer I would have gone through any and every treatment available in the hope that they wouldn’t have to go through the trauma of losing their mother.
Today, my kids are in their 20s, and happy. I love my husband and my job–but I wouldn’t feel the same obligation to stay alive.
I agree that no one can “tell” someone to give up. At the same time, both research and anecdotes suggest that sometimes dying patients are greatly relieved when a trained palliatlve care team “allows them” to acknowledge that they are dying.
In our culture, patients often feel quite a bit of pressure to keep on fighting. They feel that is what their doctors expect, or what their relatives expect.
The really sad thing is that children dying of cancer sometimes soldier on because they don’t want to disappoint their doctor and their parents.
I’ve talked to parents of children who died of cancer who realized that this was happening –and felt very torn between wanting as many days and weeks as possible with their child, and not wanting the child to suffer needlessly.
Gregory–
Yes, I think the key is to begin to pay oncologists (and other specialists) more for talking to and listening to patients–and less for
very expensive, very aggressive treatments.
In Japan, the government sets doctors’ fees, and because there is a cultural antipathy regarding surgery, doctors are paid very little for
cutting someone open.
They are paid much more for diagnosis–talking the patient and listening.
As a result, there is far less surgery in Japan than in most other developed countries. Yet, overall, health and outcomes are very good in Japan.
Dr. Rick–
Thanks much. Yes, we do need to mature, and accepting death is at the center of that.
The real issue is not treatment but society’s attitude to death.
People go to doctors because they expect them to “do something”. Doctors become doctors because the also want to “do something”. Death is the reverse of these desires, so the framing as how to proceed is already biased before any decisions are made.
Our attitude towards death is a result of the widespread beliefs in various types of supernaturalism. Even scientists (including doctors) are pushed not to tamper with people’s beliefs because they are a “personal matter”.
The consequence of this unwillingness to accept the scientific evidence for what happens to people after they are dead is even seen in the legal system. It’s why suicide is a “crime” and assisted suicide is seen as similar to murder by many.
Even people who may have rational beliefs about death have been indoctrinated throughout life that it is important to keep fighting until the end. This limits their options legally, practically and psychologically.
Anyone who might wish to end their life before it becomes too unpleasant is said to be depressed and needs to be treated. Such treatments are said to be successful when people stop trying to control their end of life actively and give in to the pressures of those fighting their “depression”.
People fear death because of lingering mystical beliefs taught to them in childhood. I’m not an anthropologist, but I think there are other cultures, not based upon the western monotheistic traditions, which are more at ease with letting people go when the time comes.
It seems that things may be changing in the west, some families are more willing to cut back on extreme measures and there is some anecdotal evidence of deliberate morphine overdose and the like being done on the sly.
As long as there is a large segment of the population which believes that steps taken to hasten death is a “sin” and therefore beyond discussion there won’t be any rational guidelines set.
I”m not interested in hearing any “slippery slope” objections. If the government is expected to come up with cost/benefit guidelines for active end of life care then why not guidelines for deliberate ending of life? Is there a difference between death by omission or commission, or is this just another residue of religious tradition?
Is Hospice helping your neighbor? They’re wonderful.
Even if all oncologists were on salary and profit wasn’t a factor, there are still a couple of issues that we need to improve upon, I think. First, the extent to which doctors deliver an end of life prognosis to the patient and the family and discuss the treatment options is uneven at best. Often, there is no discussion at all, largely because it is difficult. It would probably be helpful if a palliative care specialist could handle this if the oncologist can’t or won’t do it. I think the healthcare system probably could do a better job of making sure that every patient in an end of life situation receives an honest prognosis and is informed about available treatment options including hospice and palliative care.
One other issue relates to the plain fact that resources are finite, and these bills are being paid (for the most part) by taxpayers, insurers or employers and rarely by the patient or the family. With respect to elderly patients that have already lived beyond a normal life expectancy, I think a legitimate question can be raised as to whether or not taxpayers / society should be obligated to provide all of the care options that might be made available to younger patients.
Hello –
I am a documentary maker and hospice volunteer in Atlanta, Georgia.
I’ve produced a short documentary about end-of- life decision making, palliative care, caregiving and hospice.
It’s called 203 Days.
You can view it in its entirety at the following University of Connecticut website along with a study guide.
http://fitsweb.uchc.edu/Days/days.html
It is an unflinching look at the day-to-day interactions between patient and caregiver, in this case an 89 year old woman who is living with her daughter.
203 Days recently won the First Place 2007 Film Award from the National Hospice and Palliative Care Organization (NHPCO).
If you’d like more information please go to my website
http://bbarash.com/bb_203days.htm
I hope this film is helpful to people who want to know more about some of the most common experiences for caregiver and patient at this difficult time.
Sincerely,
Bailey Barash
I wanted to alert folks to a program that takes place at 145 medical facilities – mostly hospitals – across the country, where staff process the tough psychosocial issues that come up in patient care, including: when is it time to stop the interventions and let a patient die? These monthly sessions are called Schwartz Center Rounds, and they’re sponsored by the Boston-based Kenneth B. Schwartz Center.
At Schwartz Center Rounds this week at a Massachusetts hospital, staff were discussing a recent case of a patient with a very advanced form of cancer, who had been in a lot of pain from several complications. Shortly before his death, his family was advocating for more treatment, while the staff felt like the interventions were just prolonging his agony. One staff member said something I felt was very poignant, and relevant to this discussion: “We in the medical profession still think of death as a failure, and that has to change. We need to expand our definition of success to include helping a patient achieve a positive death.” That’s a hard pill to swallow for a lot of caregivers, especially when you have patient families asking you to do more.
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Robert, Barry,Bailey, Julie —
Robert, I complete agree that:
“Even people who may have rational beliefs about death have been indoctrinated throughout life that it is important to keep fighting until the end. This limits their options legally, practically and psychologically.
“Anyone who might wish to end their life before it becomes too unpleasant is said to be depressed and needs to be treated. Such treatments are said to be successful when people stop trying to control their end of life actively and give in to the pressures of those fighting their “depression”.
Too many of us praise dying friends and relatives for “fighting” when it might be much, much kinder to let them know that we understand that they are in pain, that they are tired, and that they have no obligation to fight for our sake. If they want to fight for their own sake–that’s fine. But not for our sake.
I know a man who was treated for depression when he was dying becuase he had horded pills and attempted suicide. His despair when they “saved him” was a terrible thing.
I don’t think the majority of people in this country are ready for “assisted suicide” as a commonplace thing. (Even in countires where it is legal, it’s not commonplace.)
But I do believe that we might start thinking about wording legislation that would protect patients and at the same time, in extreme circumstances, allow patients to choose to bring an end to their suffering, with the help of a doctor who is a) willing to do this and b) has been thoroughly vetted.
Lisa– I don’t think she’s getting hospice care, and I’m not sure why she isn’t. Both she and her husband are well-educated and politically left, so I’m sure they know about it. . .
Barry–
I agree–oncologists are not trained to talk to patients about death. Palliative care specialists are. So if the oncologist isn’t comfortable, he should call in a pallliative specialist–sooner rather than later.
And we must fund palliatve care. Right now, very few med students feel that they can afford to choose palliative care as their specialities. The have so many loans . . .
But I don’t believe that we, as a society, are ready to ration care by age. Think about it: where do we draw the line? At 85?
Say we do that. I can hear the protests: “First they come of the 85-year-olds; then they come for the 75-year-olds.. . .”
The Nazis decided that the weakest members of society were expendable. We don’t want to follow in their footsteps.
That said, I do think that people (and those they appoint to represent them) be able to make choices about whether they want to continue treatment.
Bailey– the documentary sounds very good. Thanks for the link.
Julie– I’d like to hear more about the Schwartz rounds if you want to e-mail me at mahar@tcf.org
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I’m right at 70 YO and have enjoyed excellent health all my life until a recent serious medical crisis that my doctor is trying to find the cause for.
As a result of early childhood hospitalizations I’m somewhat phobic about doctors and hospitals, probably the big reason I’ve put so much effort into good health. But I’ve mostly had truly excellent doctors when needed, to have my babies, to have a broke hip repaired and the urologist now working with me.
One thing I carried from childhood was that doctors don’t explain anything. The patient, a good patient, is a passive, silent recipient. Now, I really don’t know how to question to get the information. Maybe they assume I already know or can just decipher what’s happening by the cryptic (to me) comments. I’ve never been fearful of speaking up for myself, but also don’t want a reputation of combativeness in a setting intimidating to me.
All I really want from doctors is the truth…I don’t care if they don’t know for sure; I want their opinions as well as their clinical skills and skillful use of or referral to technology. They needn’t spend a lot of time, just be very clear, give me time to absorb, and allow me to ask “dumb” questions.
I’ve been a competent adult for many years and my age now doesn’t automatically turn me into someone who can’t intelligently process information about myself or my future. Also, I know myself better than anyone else can, have spent a lot of effort paying attention, studying. I want the doctor’s expertise and his willingness simply to share with me what’s going on, what’s likely, etc. I deserve that respect, just as the doctor deserves mine. I wouldn’t be consulting him if I had his knowledge and skills.
My “fight” will continue to be to do all I can to support my over-all good health. That takes discipline. When there is the inevitable physical breakdown and death is near, I don’t want to fight that. I want hospice care that will allow me some peace at the end and to avoid as much as possible debilitating pain. I also don’t want to fight family members who’ll “want everything done” or doctors or staff who’ll want to do everything possible. But I’m less sanguine about all that.
This is a very lucid and well researched article. I would add that after forty years of taking care of very ill patients a different, but related question should be asked regarding when the patient is going to die and further therapy at the end of life. The question to be answered is, considering the present state of health of the patient and their disease process what does further therapy offer, with its’ expected toxicities, beyond hospice and excellent palliative care,? This takes medical judgement which is at the heart of appropriate care for the patient.
Kenneth A. Fisher, M.D.
http://drkennethfisher.blogspot.com
Peggy and Kenneth–
Peggy: I think you should tell your doctor what you wrote in your post.
First, that it’s not
about him–that this comes from your experience as a child when you were taught that a good patient is passive, quiet. etc.
Now, you’re an adult, and you really wan’t to know what’s going on. And that you’d be happy to hear “At this point I don’t know, but it’s possible that X, or Y, or Z. That’s why we’re doing A, B, or C.
It sounds like you’re far from the end of your life, but it seems to me that anyone over 50 , or anyone with serious health problems, should find out which hospitals in their community have palliative care. Because a pallative care specialist (and team) is the person who is the person who is going to protect you against family members or hospital staff who want to “do everything possible.”
Surprisingly, most hospitals in the U.S. don’t have a palliative care specialist. Many hospitals in Manhattan don’t. So it’s worth knowing where you can find them before you’re admitted to a hospital.
Kenneth–
Thank you. And I agree–this is all about “judgement” and weighing many factors . . .
Is the patient/family included in the Schwartz rounds?
What does being left have to do with Hospice?
I believe some in Congress had the idea to begin paying oncologists more for talking to and listening to patients and less for very expensive, very aggressive treatments.
The Medicare Modernization Act (MMA) of 2003 changed how the CMS paid for medical oncologists’ services. It called for rewarding medical oncologists to communicate with patients and to spend more time dealing with patients’ chronic health conditions caused by infusional therapy.
Medical oncologists would be reimbursed for providing evaluation and management services, making referrals for diagnostic testing, radiation therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival. In other words, being paid to think rather than just dispense drugs.
Before, medical oncologists received no reimbursement for providing oral-dose therapy to patients. This had been the principal barrier to the availability of oral-dose protocol. The advent of oral agents ultimately meant that medical oncology had to change its identity, prior to the Chemotherapy Concession.
The MMA bill offered patients benefits they did not have before, mainly coverage for oral chemotherapy drugs. More might have been achieved if the American Society of Clinical Oncology (ASCO) and other fraternal groups had lobbied as much for the oral chemotherapy drug issue as they did for office-practice expense reimbursement. They fought long and hard to retain the Chemotherapy Concession.
The MMA bill tried to remove the profit incentive from the choice of cancer treatments, which were financial incentives for infusion-therapy over oral-therapy or non-chemotherapy, and financial incentives for choosing some drugs over others. Patients should receive what is best for them and not what is best for their oncologists.
While the MMA bill was trying to pay medical oncologists for being doctors again, instead of being in the retail pharmacy business, the private payors still go along with the Chemotherapy Concession.
right thoracic scoliosis with spina bifida occulta and law position of spinal cord at L5 instead of L1 ..all this without neural manefiestation….age/13…….girl in premenarcal period….congenital scoliosis…..X-ray show curve at 56