Changing Identity of Medical Oncology

gdpawel

Under previous law, Medicare covered chemotherapy as well as radiation treatment for cancer patients, but did not pay for oral-dose anti-cancer drugs, unless they were available in both oral and injectable form. Medicare Part B covered a total of seven oral-dose anti-cancer drugs under this provision. Older Americans were being denied access to the latest generation of cancer drugs simply because these therapies came only in pill form.

Under the new Medicare Bill (MMA) medical oncologists will 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.

The fact that medical oncologists receive no reimbursement for providing oral-dose therapy to patients had been the principal barrier to the availability of oral-dose protocol. The advent of oral agents ultimately means that medical oncology will need to change its identity, prior to the chemotherapy drug concession. Because oral-dose drugs ultimately deliver on their promise of combining equally efficacious therapy with better adverse event profiles and easier administration, they will rightfully gain their appropriate share of the marketplace, again.

The new Medicare Bill offers patients benefits they did not have before. There is now some coverage for oral chemotherapy drugs, which were not available before. Since April of 2004, $200 million was available so that some Medicare cancer patients would have transitional coverage for these drugs, until the bill goes into full effect in 2006. Although some benefit was realized, more might have been achieved if ASCO (American Society of Clinical Oncology) and other groups had lobbied as much for the oral chemotherapy drug issue as they did for office-practice expense reimbursement. ASCO fought long and hard to retain the Chemotherapy Drug Concession.

Increasingly, oral-dose anti-cancer drugs are found to treat cancer effectively and seen as a necessary part of a patient's cancer care. A number of these breakthrough cancer drugs came on to the market that are only in oral form and previously not reimbursed under Medicare. Patients were being forced to compromise their cancer care due to Medicare not covering many of these life-saving therapies.

The new legislation started the process of providing access to a full range of the latest cancer-related prescription drugs at manageable costs to enhance the quality and standard of treatment for cancer. Cancer patients under Medicare are now able to rely on treatment decisions that are dictated by good medicine and not just economics. Medicare recipients were being relagated to treating their diseases with older, more toxic infusional chemotherapy agents at a time when new and more promising cancer drugs were reaching the market.

The new targeted, relatively non-toxic oral anti-cancer drugs are based on a variety of biological mechanisms that essentially stop cancer from spreading. Targeted cancer therapies use drugs that block the growth and spread of cancer. They interfere with specific molecules involved in carcinogenesis (the process by which normal cells become cancer cells) and tumor growth. By focusing on molecular and cellular changes that are specific to cancer, targeted cancer therapies can be more effective than current treatment protocols and less harmful to normal cells.

These new products are an indispensable new feature of quality cancer care and will replace, enhance or even make more effective therapies that are largely based on intravenous administration (infusion therapy). Compared to infusional therapy, oral-dose anti-cancer drugs can make receiving cancer treatment more convenient for patients by allowing flexibility in taking medication without disrupting work or other activities. They can often result in less time (or no time) spent in office-based oncology practices because of the absence of intravenous administration and its related side-effects.

Targeted cancer therapies will give doctors a better way to tailor cancer treatment. Treatments may be individualized based on the unique set of molecular targets produced by the patient's tumor, and these important treatment advances will require individualizing treatment based on testing the individual properties of each patient's cancer. Chemosensitivity Testing (Cell Culture Drug Resistance Testing) can improve patient survival in chemotherapy for cancer.

These new differences in therapy hold the promise of being more selective, harming fewer normal cells, reducing side-effects and work to improve the quality of life for people with cancer and can translate into savings for them and overall for the health care system.

What was needed to be done was to remove the profit incentive from the choice of cancer treatments. 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.

The new system is clearly an improvement from the standpoint of cancer patients, taxpayers, and advocates of basing drug selection on individual tumor biology, rather than on a least common denominator approach which invites "conflict-of-interest medical decision-making."

gin51

Thanks for sharing this with us. What a shame that people die due to greed.

gdpawel

Neil Love, M.D. reports in a survey of breast cancer oncologists based in academic medical centers and community based, private practice oncologists. The academic center-based oncologists do not derive personal profit from the administration of infusion chemotherapy, the community-based oncologists do derive personal profit from infusion chemotherapy, while deriving no profit from prescribing oral-dosed chemotherapy.

The results of the survey show that for first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists prescribed an oral dose drug (capecitabine), while only 13% perscribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel.

In contrast, among the community-based oncologists, only 18% prescribed the oral dose drug (capecitabine), while 75% prescribed infusion drugs, and 29% prescribed the expensive, highly remunerative drug docetaxel. The existence of this profit motive in drug selection has been one of the major factors working against the individualization of cancer chemotherapy based on testing the cancer biology.

This is not to imply that the academic center-based oncologists are without their fair share of collective guilt. They were misguided in not recognizing that they were trying to mate notoriously heterogeneous diseases into one-size-fits-all treatments. They devoted 100% of their clinical trials resources into trying to identify the best treatment for the average patient, in the face of evidence that this approach was non-productive. However, such unsuccessful experiments will never be viewed as such by the thousands of people whose careers are supported by these experiments.

Henderson, et al, entered 3,100 breast cancer patients in a prospective, randomized study to compare cyclophosphamide/doxorubicin alone versus cyclophosphamide/doxorubicin plus Taxol (in the adjuvant, pre-metastatic setting). The results were microscopically positive, at best, and cannot begin to justify the enormous financial and human resources expended (while making no effort at all to test and improve methods to individualize treatment).

But these results changed the face of the adjuvant chemotherapy of breast cancer. Cyclophosphamide+Doxorubicin+Taxol became standard of care. Taxol recently went off patent. Now the thrust is to identify on-patent therapy which is microscopically better in clinical trials of one-size-fits-all treatment. Already, the community-based oncologists are migrating to Cyclophosphamide+Doxorubicin+Docetaxel (expensive/remunerative) so what was the purpose of doing that 3,100 patient prospective, randomized Henderson study?

http://patternsofcare.com/2005/1/editor.htm