Reimbursements Sway Oncologists' Drug Choices




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Received from Gregory D. Pawelski March 16, 2006.

Reimbursements Sway Oncologists' Drug Choices

A joint Michigan/Harvard study that confirms medical oncologists choose cancer chemotherapy based on how much money the chemotherapy earns the medical oncologist.

Just published in the journal Health Affairs is a joint Harvard/Michigan study entitled "Does reimbursement influence chemotherapy treatment for cancer patients?" In a study of 9,357 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 (Jacobson, M.,O'Malley, A.J., Earle, C.C., et al. Health Affairs 25(2):437-443, 2006).


The ASCO President says that we go by the literature, which has defined which are the best regimens. Well, how does he explain why the academics prescribe oral dose Xeloda to their metastatic breast cancer patients who aren't on their protocols, which keeps them from clogging up their chemo rooms and resources, which they want to use for the patients on their clinical trials, while the community oncologists almost universally prescribe infusion therapy, with the most popular drug being the still on patent Taxotere (docetaxel), which I do surmise has one of the best "spreads" between acquisition costs and average reimbursement.

This study adds to the 'smoking gun' study of Dr. Neil Love on the subject. The results of his survey show that for first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists 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 community-based oncologists, only 18% prescribed the oral dose drug (capecitabine), while 75% prescribed infusion drugs, and 29% prescribed the expensive, highly remunerative drug docetaxel. The existence of this profit motive in drug selection has been one of the major factors working against the individualization of cancer chemotherapy based on testing the cancer biology.

Once a decision to give chemo is taken, physicians receiving more-generous Medicare reimbursements used more-costly treatment regimens.

What was interesting about the "Patterns of Care" study was that it is contemporary, after the Medicare reform. It shows that the Medicare reforms haven't solved the problem. It's not that all oncologists are bad people. It's just an impossible conflict of interest, it's the system which is rotten. The solution is to change the system. So far, Medicare reform hasn't achieved that.

Two scientific "evidence-based" studies give a dose of reality. It was very personal situation for me. I didn't need these two scientific "evidence-based" studies to tell me that my wife's oncologists had the incentive to prescribe a $15,000 taxol/carboplatin combination regimen to a patient who was platinum-resistant, instead of a $1,500 alkylating agent regimen the patient had before. Chlorambucil (Leukeran) was the postoperative chemotherapy my wife had for her original ovarian cancer in 1972.

It was the slowest acting and least toxic of the alkylating agents (well tolerated oral drugs). Depression of the immune system was slow and reversible, allowing it to regenerate and contribute to recovery. A malfunctioning immune system can fail to stop the growth of cancer cells. She went twenty-four years before ever experiencing a recurrence in 1996.

The postoperative chemotherapy she received from the oncologists at our so-called community cancer center for her recurrent ovarian cancer was taxol/carboplatin. It is commonplace to give the same treatment to a recurrence (after six months) as was given for the original tumor (in my wife's case, chlorambucil). If it worked the first time, it sure has a very good chance of working again.

Patients who develop recurrent ovarian cancer more than six months after first-line chemotherapy (in my wife's case, 24 years), can experience another remission following treatment with the identical first-line chemotherapy that was previously used (in her case, Chlorambucil). But again, I didn't need two scientific studies to tell me why they did or didn't do. This is just the scientific "proof."

The information is much more important because the "Patterns of Care" shows that the Medicare reforms are still not working. It still is an impossible conflict of interest.

The last time Congress helped cancer doctors, Committee Chairman Senator Chuck Grassley found out that the value of the $300 million-a-year demonstration project for oncology to report on a cancer patient's level of nausea, vomiting, pain and fatigue was for nothing.

Providers were being paid an additional $130 per infusional-chemotherapy recipient per treatment day to simply forward data that had already been collected. This year, Congress is being hoodwinked into some other financial incentive to reimburse oncologists that report whether their treatment adheres to practice guidelines published by either NCCN or ASCO.

It's called the "Community Cancer Care Preservation Act (S2340), just introduced by Senator Arlen Spector. I would encourage cancer advocates to write their U.S. Senators and ask them to delete these harmful aspects of the proposed bill. They need to be eliminated, not continued. And continue exposing these two studies, so as many cancer patients as possible will understand.

Gregory D. Pawelski

Cancers where chemotherapy may be of value include "acute Iymphocytic leukemia, Hodgkin's disease, and nonseminomatous testicular cancer. Also, a few very rare forms of cancer, including choriocarcinoma, Wilm's tumor, and retinoblastoma. But all of these account for only 2% to 4% of all cancers occurring in the United States."  Moss.


Cancers where radiation therapy may be useful include "early Hodgkin's disease, lymphosarcoma, inoperable local prostate cancer, and localized tumors of the head, neck, and cervix. With these significant and noteworthy exceptions, the vast majority of studies show that radiation cannot cure cancer, and that it does not usually extend life for people with the disease." - Robbins, pages 229 - 230.   



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