This last week I was traveling and experiencing the amazing sights of Georgia (the nation, not the state). Following my usual pattern, I used the Membership Directory and reached out to fellow ASCO members in Tbilisi. Drs. Nino Sharikadze and Tako Esakia were kind enough to join me for a great dinner and exchanging of stories. Surrounded by cigarette smoke (an experience I had forgotten but one that remains all too common in Georgia), some interesting and difficult differences from our practices in the U.S. came to light.
Georgia regained independence from the former Soviet Union in 1991, and that independence was tested sorely in 2008. The medical community has had to do a lot of rebuilding in a relatively short time. The large cancer center model has not really survived. Practices, instead, exist as separate entities much like our community practices of the 1970s. They still put great effort into multidisciplinary care, however.
The notion of patient privacy and HIPAA is very different. Family is very important in Georgian culture and that extends to interaction with physicians. We may inwardly cringe a bit when we walk into a room with a patient and 4 to 5 relatives. For Drs. Sharikadze and Esakia, that would be an easy way to handle things. It can actually be common for them to have spouses, children, and even cousins ask to talk with them before they even see the patient. I just cannot even imagine.
The aspect of oncology care in Georgia that really floored me was the impact of newer drugs and their cost on patients. The notion of financial toxicity is becoming more widely discussed in this country. Even though our patients in the U.S. may only be paying 10% to 20% of those costs, we are recognizing how that can impact their care and lives. Contrast that with Georgia. Citizens of Georgia who live below the poverty line have insurance provided by the country. People above the poverty line purchase insurance or pay completely out of pocket. Out-of-pocket charges can be high, even with insurance. Coverage for usual cytotoxic drugs is provided. What is not covered, with one exception, are targeted therapies. There has recently been an approval for trastuzumab in younger women with breast cancer. The newer therapies that we are so excited about and that may be actually revolutionizing our care? Not covered at all. Patients are required to pay the entirety of the cost out of pocket. Patients (and often their families as well) are draining savings, selling houses, and liquidating any assets they can to receive these therapies.
Needless to say, this puts a great burden on the oncologist’s shoulders. Ethically, it is a difficult notion to say that the patient should not be informed of the therapy because of the financial impact. When oncologists in Georgia are asked, as we all often are, “Doc, what do you think…should I do this?”, the answer isn’t easy. If you are considering a patient who is unlikely to survive 18 months and they would leave survivors with no home, savings, or other resources, how quickly do you say, “Yes, do this.” I certainly do not envy them this burden.
As we further consider the idea of financial toxicity in the U.S., reaching out to members in countries like Georgia for their ideas should be a given. They have been dealing with the issue in a much larger fashion then we have, and likely have unique perspectives on the topic.