Finding Doctor Right
A Commonsensical Guide to Seeking the Best Oncology Care in the Galaxy for One Newly Diagnosed With Cancer
K udos to the editor of this magazine, the very fact that you are reading this means my conjuration of words is seeing the light of day, courtesy of an undoubtedly enlightened editing mind. Okay, enough sycophancy.
Many people when diagnosed with cancer look to their family physicians for advice when faced with a bewildering array of diagnostic and therapeutic options. The most common scenario is a patient who has undergone surgery to remove a cancerous growth or a biopsy that confirmed the diagnosis of cancer. How should they proceed?
With the liberalization of advertising regulations for doctors, it is common for one to find adverts peddling cancer care in the classified sections of printed media nowadays. Cancer care information also feature rather regularly in our local dailies and their supplements. These supplements may be sponsored by healthcare organizations which will inevitably highlight the strengths of their respective services and expertise through the regular columns penned by their health professionals.
Specialists also tend to recommend therapeutic modalities skewed towards their sub-specialties. For example, this means that an elderly patient diagnosed with early prostate cancer may be offered surgery by the urologist, radiotherapy by the radiation oncologist, or HIFU (high frequency ultrasound ablation) by whoever who may have the HIFU machine. All will be rather bewildered and perplexed after such a myriad of diverse service providers screaming for their attention. The crux is – is there a comparative benefit among these different therapeutic modalities? This leaves the well-informed family physician as their patients’ most ardent advocate to be the last bastion of unbiased opinion to guide them through this potential minefield.
Do all roads lead to Rome?
The first question a patient will usually ask is – where should I go for treatment? If the surgery is not done yet to extirpate the primary tumour, should I remain in the public sector or the private sector? This will depend on the type of tumour it is. If it is a common cancer such as colorectal cancer, there is no significant clinical difference in outcome for the patient whether the surgery is done in a low volume or high volume centre. However, if it is a rare tumour, such as a primary bone tumour, it will be prudent for the patient to be attended by a surgeon who specializes in this field because even the biopsy, if not done properly, may jeopardize subsequent surgical clearance of tumour. For rare tumours, centres with higher volume of such surgeries have consistently been proven to do better.
As for chemotherapy drugs, the oft expressed fear of the public service giving sub-standard chemotherapy drugs and lack of availability of targeted therapy is entirely based on sheer ignorance and due partly also to malicious propagation of this falsehood by certain medical practitioners with less than altruistic intent. The drugs available in the private and public sectors are the same. Any drug that is used exclusively in one centre and entirely novel will have to be administered within the setting of a clinical trial. The public centres in this context will allow greater access to these novel drugs than in the private sector. Claims that a certain drug is available only in a particular clinic or centre will have to be viewed with circumspection. We shall discuss clinical trials later.
So what is the difference between private and public sector cancer care? Why the big variance in drug costs? Although frequently accounted for under drug price, the additional cost, in truth, is charged for the premium of provision of highly personalized care by a specialist and this kind of care is impossible to render in the public sector given its tremendous patient load. The total waiting time for laboratory tests, scans and medical consultation in the public sector is on average significantly longer than that compared to each treatment encounter in the private sector. For someone who is ill with cancer, these precious extra hours may be better spent outside of the cancer centre or clinic, with friends and family.
The Cardinal Sins
The following tell-tale signs, if displayed by a particular medical practitioner, suggests that your patient may be better off seeking another opinion or treatment elsewhere before making a decision on accepting a recommended therapeutic option.
Exaggeration of benefit of treatment.
I am frequently bemused by how data is always twisted to favour treatment versus no treatment. This is not right. It skews the patient’s judgment towards treatment with cytotoxics or targeted therapy. For example, breast cancer recurrence risk over 10 years for a particular type of early stage breast cancer after surgery may be 5%. With chemotherapy, the recurrence risk reduction may be by 2% over 10 years. The patient is frequently told that the relative risk reduction is 40% (2% of 5%). This information while
true is misleading. Your patient should be told to ask for absolute risk reduction because if told that it is only 2%, she may not opt for chemotherapy.
Hefty deposit to be paid for entire course of treatment.
This sort of subtle commercial coercion belongs to the realm of spa packages and not in the setting of oncology care. It binds patients through economic means to treatment which they may wish to discontinue and deters them from changing oncologists by imposing a financial disincentive through loss of deposit.
“This drug is only available in my centre or clinic.”
As explained above, no centre has exclusive access to any drug unless it is within the confines of a clinical trial which the centre or clinic has committed to be a participating trial site.
“It will be beneficial for you to join this clinical trial.”
No one truly knows whether a clinical trial will be beneficial for a patient who enrols in it. The purpose of a clinical trial is to investigate the efficacy of a drug, not to confirm known benefit. The question to ask the doctor will be – if I am your well-loved family member, will you still urge me to consider joining this clinical trial? There are many instances whereby an oncologist may not even recommend a particular trial to their family member who has cancer given that all inclusion criteria are fulfilled.
“There are no other options other than this drug.”
This stems from the failure to understand that whatever the USA FDA (Food and Drug Administration) approved as a drug of choice allows reimbursement for that drug in the US healthcare system after rigorous review of the data for that drug. But in Singapore, it does not bind an oncologist to use only an approved drug that is frequently expensive since patent rights are still in force, especially in the setting of controlling cancer in the non-curative setting, to the exclusion of other useful and cheaper drugs that are not considered as the current sole approved agent for that particular cancer. While US FDA approval is a good guide for sound clinical practice, it should not be followed to the letter in all instances. There are always options.
“You must have treatment today!”
It is very rarely that emergent chemotherapy is needed. It is truly needed in a few dire situations involving germ cell tumours and haematological cancers such as lymphoma and leukaemia. But such occasions are rare and your patient will be experiencing very acute symptoms and display clinical signs that portend the presence of a life threatening condition. A second opinion will help clarify the situation. The converse is rarely expressed – that treatment can wait for a few more months without adverse outcome in your patient. The latter may be ill-judged too.
The good family physician who is an adept practitioner of general medicine will be able to sieve the wheat from the chaff in oncology care with regard to the holistic well-being of the patient. Setting to good order family ties in need of reparation and maintaining dignity is definitely more important than scoring pyrrhic victories with treatment for the terminally-ill with cancer. On the other hand, unjustified fatalism should be decisively dispelled for treatment that may be difficult to undergo, but potentially curative regardless of a patient’s age or station in life. So what is that all important requisite for advising such a patient of yours? A good heart, that’s all
Dr Donald Poon underwent advanced specialty training in medical oncology at National Cancer Centre, Singapore (NCCS), and was the Honorary Medical Director of Singapore Cancer Society from 2007 to 2009, and founding President of the Society of Geriatric Oncology in Singapore. Dr Poon is the national representative of Singapore in the International Society of Geriatric Oncology. In recognition of his efforts in patient care, he received the Humanity Healthcare Award in 2006 and STAR Excellent Service Award in 2009. He is also an active clinical investigator in multiple investigator-initiated and pharma clinical trials. Dr Poon is currently a Specialist in Medical Oncology at Dr DYH Poon & Associates.