This article is more than 5 years old. Information may no longer be current.
Despite challenges in US cancer care, things could be a lot worse
Click Here to Manage Email Alerts
“When my bankroll is getting small
I think of when I had none at all
And I fall asleep counting my blessings”
— Bing Crosby
This morning, I received a letter from a medical student in the United Kingdom who wants to come to our institution for a student elective in the summer.
In his request, he mentions he would like to get some insights into “international differences in clinical practice.”
By coincidence, I am writing this editorial on Jan. 20 — the day of President Donald J. Trump’s inauguration.
Please be assured that I am not about to get into politics.
The date is significant because of the uncertainties we now face regarding the future of health care in general — and of cancer care in particular — and what impact “repeal and replace” ultimately will have.
It is very difficult to speculate on what the future holds, but as we prepare for new transitions in our cancer care delivery model, I am reminded of how fortunate we are in many respects and of how — despite the challenges we face delivering patient-centered, high-quality cancer care — things could be worse.
When the system fails
Just before Christmas, I received an email from a friend in the United Kingdom. I’ll call him Frank.
Frank is in his mid-60s, previously very healthy, runs his own business and is very active in his community.
He had some urinary symptoms, saw his primary care physician in the fall and subsequently was referred to a urologist. After about 8 weeks, he saw the urologist, underwent evaluation — including a PSA and subsequent biopsy — and was diagnosed with locally advanced prostate cancer. In mid-December — 3 months from his original consultation — he was seen by a medical oncologist for the first time, who ordered further imaging, including a CT/PET scan.
Although he was seen at a large university hospital, he could not get a CT/PET there. Instead, it was scheduled at an affiliated hospital about 50 miles away — the earliest this could be done was mid-January. At this point, he contacted me to ask for some information and some guidance.
I sought advice from our genitourinary oncologists and facilitated a second opinion by e-consult with an internationally renowned genitourinary oncologist based in the United Kingdom. Based on his advice, Frank went ahead with his CT/PET in mid-January, with a plan to reconnect with this international expert when the result was available.
There was a lag of 8 days after the imaging was done until the result was available to Frank. After careful evaluation of his imaging, he was advised to return to his local oncologists and be treated on a randomized trial. He will start chemotherapy next week.
Frank and I are both confident he will get excellent care. Overall, he is very comfortable with his care team, his primary oncologist and the management plan, which he feels has been explained to him thoughtfully and compassionately.
But Frank’s story is disturbing. He is a highly educated, successful man who believes in the government-funded National Health Service (NHS). Having placed his faith in this system, I cannot help but think that — at some level — it has failed him.
It has taken almost 4 months from diagnosis to treatment, and his ability to even get a second opinion — which did not further delay his therapy — was partly because of my ability to “work” the system through my professional contacts, a resource that most patients in Frank’s position would not have.
I do not know if this apparently slow progress through evaluation is normal within the NHS or whether it has any impact on the ultimate outcome — which I doubt — but that is not the point. Whatever the impact on outcome, this has not been a patient-friendly nor a patient-centered experience for him or his family, who have endured weeks of uncertainty, anxiety and apparent inactivity.
The individual experience
I need to make it clear that the purpose of telling this story is not to be critical of the U.K. health system.
I trained and worked within that system for more than 20 years, and U.K. citizens are rightly proud of the many achievements and advantages of the NHS, which is widely recognized as effective and comprehensive.
Ask a patient in the United Kingdom who has very limited financial resources and no private health insurance but has access to an expensive drug or a bone marrow transplant if needed, and you can immediately understand the sense of security that the NHS provides.
But it comes at a price. Underlying the “big-picture” demonstrations of the efficiency of the system are individual stories like Frank’s. Regular readers of HemOnc Today may remember an account Jai. N. Patel, PharmD, provided in the Sept. 25 issue about his experiences in a London hospital — adequate care but not very patient centered.
As a former U.K. oncologist now practicing in the United States, I am frequently asked about differences between the two health care systems.
I have several answers to that question.
One major difference is the comparatively lower funding of the U.K. system, but Frank’s experience has reminded me that another difference is the expectation of our patients. I doubt if there are many patients with a recent prostate cancer diagnosis in the United States who would tolerate the slow pace of workup that he received, and they would be right. Whatever the eventual outcome, this was not patient-centered care, and remember that this is a highly sophisticated, relatively wealthy, Western European nation.
Imagine how much more pronounced these contrasts become in nations with major resource limitations. The National Cancer Policy Forum’s workshop on cancer care in low-resource countries reminds us of the challenges those nations face, as well as the good fortune we enjoy in the United States.
So, as I reflect on the request from this medical student, I think we are in a position to show him some very practical differences in international clinical practice and the very real impact these have on the patient experience.
Despite all of the problems we face in U.S. cancer care — including the challenges of addressing disparities, the rapidly rising costs of care, the inadequacy of some of our prevention and screening strategies, and the rising incidence of these diseases in our population — when our patient-centered care works well, it is, without question, among the best in the world.
So, whatever happens after Inauguration Day, let us hope that the new administration recognizes the challenges we face, but protects the concepts of patient centeredness, quality and value that make cancer care in the United States — at its best — so special.
Despite the inefficiencies of the system, having moved from a chronically under-resourced system in the United Kingdom, Bing Crosby’s words resonate.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director of Huntsman Cancer Institute at University of Utah. He can be reached at john.sweetenham@hci.utah.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.