A Very Open Letter from an Oncologist

[gpawelski]

A Medical Director at California Cancer Care, an oncology practice in Northern California wrote a candid letter to the Health Beat blog by Maggie Mahar. He is a member of The Century Foundation's Working Group on Medicare Reform. A very experienced and successful oncologist who has served on the board of the American Society of Clinical Oncology and the Association of Northern California Oncologists.

http://www.healthbeatblog.org/2009/01/a ... ogist.html

[RandyW]

Thought Provoking Thanks Greg!!

[Donna G]

I really am glad I did not go to this doctor. The statement that most cancers are not curable by chemo to me is weird. As most cancers are curable. I know that it was chemo and radiation that started my treatment to make me operable etc. I have been cured!

Donna G

[gpawelski]

Even today, 90% of all drug cures for cancer occur in only 10% of cancer types that are intrinsically drug-sensitive, e.g. acute childhood leukemia, testicular cancer and Hodgkin's disease.

Breast, prostate and ovarian cancers represent malignanicies in which the development of drug-resistant forms has prevented significant cures with current conventional chemotherapeutic agents.

A high degree of drug resistance is also associated with cancers of the liver, colon, pancreas, kidney and lung. Chemotherapy "resistance" is the major cause of cancer treatment failure. In that case, knowing which chemotherapy agent(s) will or will not work is essential.

[Donna G]

I googled Gregory D. Pawelski and found 19 pages of hits. You seem to have been working hard to get people not to use chemo. I also want to say you have my prayers for you suffering the hardship of loosing your wife to Ovarian Cancer.

Donna G

[Donna G]

As I said I had NON small cell lung cancer and had chemo before surgery and at surgery they found it all dead.

[Donna G]

Also I do want to mention I have several friends with SCLC which is well known for being "incurable" but they have been treated with Chemotherapy and have survived for many years with no signs of progression and enjoying a very good quality of life.

Donna G

[gpawelski]

Donna G

Posting that I seem to have been working hard to get people not to use chemo is very disingenuous. I've been on the internet long enough for people to know it is blatantly untrue.

I tend to write on controversial cancer topics. In general, I provide a much needed balance to the flow of cancer information, which is largely controlled not by bad people, but by people with their own biases and self interests.

It's a fact that the choice of chemotherapy correlates significantly with reimbursement to the treating oncologist. Three decades of prospective, randomized trials in literally hundreds of thousands of patients have, in most cases, failed to define most optimum treatment regimens.

With this being the environment, oncologists tend to choose treatments based on the advantage to the oncologist, more so than to the patient. This is documented in the peer review literature, and supported by unbiased independent studies published online, by candid statements heard in small gatherings at CME meetings, and by private conversations with individual oncologists.

No one has ever suggested the need to perform prospective randomized trials between treatments chosen in the presence and absence of the profit motive. There is a compellingly greater need for such studies than for a great many prospective randomized studies which continue to be pursued.

It is a fact that progress in the most important forms of cancer with regard to drug selection has been negligible. It is a fact that the impact of taxanes has been over-hyped. It is a fact that the prognosis of metastatic breast cancer hasn't improved in thirty years, despite the enrollment of hundreds of thousands of patients in prospective randomized trials.

What important progress may occur will likely come from radically new drugs, rather than from countless iterations of trials to fine tune the administration of the old drugs (including taxanes). It is a fact that advances in the treatment of advanced ovarian cancer are owing much more to improved surgery than to improved chemotherapy and that chemotherapy progress in ovarian cancer has been grossly overstated.

I write a lot about the field of cell culture testing (cell function analysis). I'm probably not right about everything, but I care about cancer patients and cancer families no less so than oncologists and NCI researchers. I get nothing out of my endeavors. No pay. No lectureships. No junkets. Not even any free meals. I stand up for what I say by signing my own name (were I'm able).

I'm providing information and a point of view. I'm not making a decision for anyone. The cancer patient's oncologist still holds all the cards in steering the cancer patient in the direction the oncologist wishes. I am simply giving the cancer patient and his/her family a little more information in the most difficult of situations.

People who don't want this information don't go on internet blogs looking for it. People who do want this information have their own responsibility to be capable of dealing with the unfiltered information they receive in this medium.

[gpawelski]

A private practice oncologist told me years ago about a patient of his. The oncologist takes his vacation at the end of August. The patient was supposed to come in for chemotherapy on Wednesday, the day before the oncologist left. The patient couldn't make it. The oncologist, therefore, did what he always did in that situation, wrote a prescription to be "filled" at a nearby, large, comprehensive, NCI-designated cancer center. Had the patient received treatment in the office, the oncologist would have received $6,000, which the oncologist said was very generous. The NCI-designated cancer center, however, billed $28,000, and was paid 75% of this amount. (The oncologist knows about the large disparity between what the NCI cancer centers get and what he gets). I thought this was very revealing.

In 2007, NCI launched the Community Cancer Centers Program, a three-year pilot phase of a new program that is supposed to help bring state-of-the-art cancer care to patients in community hospitals across the United States. The program is designed to encourage the collaboration of private-practice medical, surgical and radiation oncologists, with close links to NCI research and to the network of 63 NCI-designated cancer centers principally based at large research universities. Wed the NCI-designated cancer centers with the community cancer centers. NCI-designated cancer centers are a very large business which act as a base of power for academic clinical oncologists who made a mess of clinical cancer research, since the time Nixon first declared war on cancer. http://blog.aperio.com/articles/Fortune_Cancer.pdf

[recce101]

Before getting embroiled in the back-and-forth, please read this:

http://cancergrace.org/forums/index.php ... 7#msg13657

Ned

[gpawelski]

And Dr. Pennell seemed to be appalled by Dr. West's response.

In regards to the Swedish Cancer Institute in Seattle, Washington and the cancergrace.org, there is an attempt at educating the physicians there about the cell culture assay technology. I've had a number of email exchanges with Dr. Jack West because he had redacted my reponses to the cancergrace.org postings about the technology and banned me from the site. He has admitted to me that he was not any kind of expert on cell culture assays. However, his intelligence does not preclude him from gaining an understanding of the technology.

Dr. Larry Weisenthal has offered to educate Dr. West and hopefully his other colleagues. Dr. West is actually quite a decent guy and he is giving Dr. Weisenthal a decent shot at presenting the case about all of this. He is giving him the benefit of the doubt, at this point, and giving him the opportunity to grow a bit. Dr. West has a lot of credibility and could be of great help with respect at educating his own colleagues, once he's been duly educated. So, it's worth a try.

Selling cancer chemotherapy with concessions creates conflicts of interest for oncologists

The shift in the United States, more than 20 years ago, from the institution-based, inpatient setting to community-based, ambulatory sites for treating the majority of the nation's cancer patients has prompted in large part additional costs to the government and Medicare beneficiaries. The Chemotherapy Concession gave oncologists the financial incentive to select certain forms of chemotherapy over others because they receive higher reimbursement. This was first brought to attention at a Medicare Coverage Advisory Committee meeting in 1999, in Baltimore, Maryland (1).

Typically, doctors give patients prescriptions for drugs that are then filled at pharmacies. But medical oncologists bought chemotherapy drugs themselves, often at prices discounted by drug manufacturers trying to sell more of their products and then administered them intravenously to patients in their offices.

Not only do the medical oncologists have complete logistical, administrative, marketing and financial control of the process, they also control the knowledge of the process. The result is that the medical oncologist selects the product, selects the vendor, decides the markup, conceals details of the transaction to the degree they wish, and delivers the product on their own terms including time, place and modality.

A joint Michigan/Harvard study confirmed that before the new Medicare reform, medical oncologists are more likely to choose cancer drugs that earn them more money (2). A "Patterns of Care" survey showed results that the Medicare reforms have not solved the problem of variations in oncology practice (3).

A patient wants a physician's decision to be based on experience, clinical information, new basic science insights and the like, not on how much money the doctor gets to keep. A patient should know if there are any financial incentives at work in determining what cancer drugs are being prescribed.

I would imagine that some are influenced by the whole state of affairs, possibly without even entirely admitting it. Social science research shows that people can be biased by self-interest without being aware of it. There are so many ways for humans to rationalize their behavior (4).

The U.S. government wasn't reducing payment for cancer care under the new Medicare Modernization Act (MMA) of 2003. They were simply reducing overpayment for chemotherapy drugs, and paying cancer specialists the same as other physicians. The government can't afford to overpay for drugs, in an era where all these new drugs are being introduced, which are fantastically expensive (5).

Although the new Medicare bill tried to curtail the Chemotherapy Concession, private insurers still go along with it. What needs to be done is to remove the profit incentive from the choice of drug treatments. Medical oncologists should be taken out of the retail pharmacy business and force them to be doctors again (6).

1. http://weisenthal.org/hcfa_1.htm http://weisenthal.org/hcfa_2.htm http://weisenthal.org/hcfa_3.htm

2. http://content.healthaffairs.org/cgi/co ... t/25/2/437

3. http://patternsofcare.com/2005/1/editor.htm

4. http://jama.ama-assn.org/cgi/content/full/290/2/252

5. http://www.medicare.gov

6. http://ethicsjournal.umc.edu/ojs2/index ... sue/view/4

[gpawelski]

If anyone took these chemotherapy drugs between January 1, 1991 to December 31, 2004, you may receive reimbursement if you made a percentage co-payment or full payment for the following drugs:

Blenoxane

Cytoxan

Etopophos

Paraplatin

Rubex

Taxol

Vepesid

Over the course of the 1990's, oncologists have been able to rely on the "sale" of chemotherapy drugs as an important source of revenue. Some oncologists acknowledge that the system created a perverse incentive. According to Dr. Edward L. Braud, from the Association of Community Cancer Centers, whose members treat more than half of the nation's cancer patients, the potential for conflicts of interest was troubling.

A study by the General Accounting Office (GAO) found that physicians were able to purchase cancer medications and other Medicare-covered drugs at prices significantly below AWP. The GAO found that the average difference between a covered drug's reported AWP and its widely available discount price - referred to as "the spread" by medical professionals - ranged from 13 percent to 34 percent. There were two drugs identified as having spreads of 65 percent and 85 percent.

Several prominent cases, drug companies have been accused of using discounts to influence doctors. In a Minnesota lawsuit, Pharmacia was accused of having induced physicians to purchase its drugs, rather than competitiors' drugs, by persuading them that the wider "spread" on the defendant's drugs would allow the physicians to receive more money and make more of a profit, at the expense of the Medicaid program and Medicare beneficiaries.

Federal laws bar drug companies from paying doctors to prescribe medicines that are given in pill form and purchased by patients from pharmacies. But companies can rebate part of the price that doctors pay for drugs, which they dispense in their offices as part of treatment. Doctors receive the rebates after they buy the drugs from the companies. But they also receive reimbursement from Medicare or private insurers for the drugs, often at a markup over the doctors' purchase price.

Such inflated payments not only placed additional strain on the finances of the Medicare program, but also directly affected beneficiaries by inflating their required 20% copay. In addition, analysts have suggested that the varying spreads for different types of physician-administered medications create a conflict of interest which could affect the treatment decisions of some health care providers.

http://www.bmsawpsettlement.com/