The Culture of Cure in Cancer Care

The Culture of Cure in Cancer Care

Abdul Rahman Jazieh, MD, MPH

@jaziehoncology
Oct 25, 2011
I always wonder whether we have our goals of care prioritized properly when we are caring for our cancer patients. I have many reasons to believe that we may not be doing enough to save every life that can be saved, starting with the work setting being named erroneously as a “Healthcare System,” when it should be called a “Sick Care System”; even caring for the sick has much room for improvement with more than 100,000 annual deaths from medical errors and double that number of preventable deaths from thromboembolic diseases, in the United States alone. This casts a shadow of doubt about the preparedness of this system to be an appropriate infrastructure for the culture of cure.

However, when focusing on cancer care, there are additional challenges to spreading the culture of cure. Prevailing pessimism among the public and many health care professionals, including some oncologists, presents the first line of challenges, which get further compounded by inappropriate processes, infrastructures, and access to care.

There is a need to revolutionize the way cancer education is conducted with more focus on how to identify curable cases and manage them properly and how to manage preventable causes of death. We need to simplify our education approach to help physicians distinguish between the “nice to know” from the “must know.”

The philosophy of cure should be crystallized, delineated, and disseminated widely. Having cure-oriented management guidelines is critical. It does not make sense to categorize therapy that prolongs survival for a few days as level I evidence while treatment that cures 90% of patients also carries level I evidence. We call both “standard of care” and we judge practitioners by their adherence to this standard. Why do we focus on the median survival of patients when not much attention is paid to the tail of the curve?

Are our multidisciplinary tumor boards optimistic enough to look for curable cases among the borderline cases? When in doubt, do we always give patients the benefit of the doubt?

I do not think anyone has a magic stick, but unless we put this issue for consideration and serious debate and discussion, we will not have the substantial changes necessary to save more lives; we will continue to drown in the flood of information that is “nice to know” but will not provide an iota of help to our patients.

I would like to hear feedback about how to establish and promulgate the culture of cure starting with the definition of cure, which I intentionally avoided discussing, to the components of this culture and the steps to instill it in our practitioners and our systems. How can we demystify oncology education to make it more effective in saving more lives? Why are internal medicine residents trained to manage MI and do cardiopulmonary resuscitation and other very complex tasks, yet get paralyzed and call for immediate oncology consult when they see a mass that “looks like”  cancer or  “may be” cancerous?

Just wondering!

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Comments

Maher Saifo, MD

Nov, 26 2011 11:49 AM

 
First I’d like to thank you for this interesting topic that is highly important especially in our Middle Eastern society. Well, regarding the definition of cure, I would say in general Cure is to kick down the entire bulk of tumor including G0 cells and restore to good health. Cure, in particular, is a time without recurrence.
Although I’m optimistic when I look at some of the borderline cases, the treatment that cures 90% of patients and the improvement of relative survival in advanced solid tumors by using systemic therapy, the current cure rates are still limited. For instances, in metastatic CRC the response rates of FOLFIRI or FOLFOX regimens are 39% and 50.7% respectively(Saltz et al) and (De Gramont et al). Treatment with docetaxel and prednisone against metastatic CaP resulted in a median survival of 19.2 months. Docetaxel in combination with cisplatin and 5-FU against inoperable advanced HN SCC resulted in a median progression free survival of 11 months.
Despite the addition of anti-EGFR and anti-angiogenesis therapies in MCRC, the median OS ranges between 20-26 months. In addition, once resistant-refractory to treatment, the OS is typically < 6 months.
Accordingly, the current cure rates are still limited indeed and the development of better clinical outcome is greatly needed to establish the culture of cure and to instill it in our practitioners.
Finally I do agree with what you said “we need to revolutionize the way cancer education is conducted with more focus on how to identify curable cases and manage them properly and how to manage preventable causes of death”.
 
 

Abdul Rahman Jazieh, MD, MPH

Nov, 27 2011 1:32 PM

Thank you very much for the comment, Dr Saifo. 
I agree with you about the limited overall CURE value of available therapies in advanced solid tumors in general. It all comes to rather an unusual fact, which is: The endpoints selected for clinical trials become the treatment goals of our patients care. That in itself may hinder further search for better treatment and compete on resources. If a study designed to palliate symptoms or even delay their occurance, then that how we will use the drug in our patients. We even put thousands of patients on comparative trials of agents that are non-curative, and does not even come close to achieving complete remission.. But the field is changing rapidly with the recent approaches about targetd therapy. We hope we focus on the first rule of cancer cure that I mentioned in my second blog: get therapies that eliminate the disease... not band-aid.

Maher Saifo, MD

Feb, 10 2012 3:54 AM

Dear Dr Jazieh,
First , sorry for replying late due to the mandatory military service.
In the Tuberculosis , the cultures of cure were completely different before and after the curing treatment was determined.
I am checking your second one and I ll reply later.
Maher


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