Chemotherapy Recommendations Based on Published Reports of Clinical Trials
The American Society of Clinical Oncologists (ASCO) says oncologists should make chemotherapy treatment recommendations on the basis of published reports of clinical trials and a patient’s health status and treatment preferences.
How about published reports of clinical trials?
More chemotherapy is given for breast cancer than for any other form of cancer and there have been more published reports of clinical trials for breast cancer than for any other form of cancer.
According to NCI’s official cancer information website on state of the art chemotherapy for recurrent or metastatic breast cancer, it is unclear whether single-agent chemotherapy or combination chemotherapy is preferable for first-line treatment. At this time, no data support the superiority of any particular regimen. So, it would appear that published reports of clinical trials provide precious little in the way of guidance (1).
In the total absence of guidance from published reports of clinical trials then, what basis are treatment regimens selected instead? ASCO says that this should be further based on a patient’s health status and patient treatment preferences.
So what is being done?
Published in the journal Health Affairs is a joint Harvard/Michigan study entitled, Does reimbursement influence chemotherapy treatment for cancer patients? The authors documented a clear association between reimbursement to the oncologists for the chemotherapy of breast, lung, and colorectal cancer and the regimens which the oncologists selected for the patients. In other words, oncologists tended to base their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist (2).
A March 8, 2006 New York Times article described the study. One of the more interesting aspects of the story was a comment from an executive with ASCO, Dr. Joseph S. Bailes, who disputed the study’s findings, saying that cancer doctors select treatments only on the basis of clinical evidence (3).
So ASCO’s Dr. Bailes maintains that drugs are chosen only on the basis of clinical evidence. Yet, Dr. Neil Love reported in a survey of breast cancer oncologists based in academic medical centers and community based, private practice medical oncologists. The former oncologists do not derive personal profit from the administration of infusion chemotherapy, the latter oncologists do derive personal profit from infusion chemotherapy, while deriving no profit from prescribing oral-dosed chemotherapy.
The results of the survey could not have been more clear-cut. For first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists (who are motivated to keep off-protocol patients out of their chemotherapy infusion rooms to reserve these rooms for on-protocol patients) prescribed an oral-dose drug (capecitabine), while only 13% prescribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel. In contrast, among the commuity-based oncologists, only 18% prescribed the non-remunerative oral-dose drug (capecitabine), while 75% prescribed remunerative infusion drugs, and about 40% prescribed the expensive, highly remunerative drug docetaxel (4).
There are patients who have progressive disease after first-line therapy, only to enjoy a dramatic benefit from second or even third line therapy, and these patients would have been much better served by receiving the most probable active treatment the first time around. While being faced with a large number of choices of otherwise equally acceptable therapies, oncologists select the treatments which generate the most income for private practices or generate the least inconvenience for the clinical research institutions.
What needs to be done is to remove the profit incentive from the choice of chemotherapy treatments. Medical oncologists should be taken out of the retail pharmacy business and let them be doctors again.
(1) http://www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page8#Section 297
(4) http://patternsofcare.com/2005/1/editor.htm (figure 37, volume 2, issue 1, 2005)