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© 2002 American Society for Clinical Oncology
Referral to Medical Oncologists: Are There Barriers at the Gate?Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, NY THERE WAS A TIME when the benefits of chemotherapy and the practice of medical oncology had still not made a deep impression on most medical practitioners. Surgery, particularly radical surgery, could cure some fraction of cancer patients with solid tumors if the tumor was caught early, and radiation therapy, dating back to the turn of the last century, could also improve survival and certainly palliate symptoms in a substantial number of cases. But what about chemotherapy? For some "liquid" tumors, chemotherapy was successful; it could cure Hodgkin’s disease and some other lymphomas, a significant number of certain leukemias, and some cases of testicular cancer. However, most of these conditions were relatively uncommon, certainly when measured against the burden of nonhematologic malignancies. The perception was that the vast majority of such patients would gain little or nothing from a therapeutic point of view by an encounter with a medical oncologist. Times have changed. New drugs, and the better use of available drugs, have produced gains in disease-free survival, notably in the adjuvant settings of breast and colorectal cancer.1-3 Prolongation of survival, even in advanced cases, is also achievable, and many cancers, if not most, have some claim to chemotherapy-derived efficacy. These changes have paralleled the growth of our specialty and the American Society of Clinical Oncology, as well as the Journal of Clinical Oncology, now in its 20th year of publication. These gains have resulted from the extensive use of clinical trials to identify active drugs and combinations and then to test their efficacy. Randomized clinical trials of chemotherapy demonstrate superior outcomes in survival from adjuvant chemotherapy in breast and colorectal cancer,1-3 the feasibility of less disfiguring operative procedures in breast cancer and limb-sparing surgery in bone sarcomas with no loss in survival,4,5 and even improved quality of life and survival for advanced lung cancer.6 The Surveillance, Epidemiology, and End-Results (SEER) program of the United States National Cancer Institute combines data from approximately 10 population-based cancer registries, which cover approximately 14% of the United States population. It contains demographic and tumor-related information as well as survival outcome, but it lacks information on chemotherapy use and other clinical details. The recent proliferation of large-scale computerized databases, generated primarily for administrative and billing purposes, such as the Centers for Medicare and Medicaid Financing (formerly the Health Care Financing Administration) or Medicare database, can provide billing information on the use of drugs and medical care. Potosky et al7 have linked the SEER database with Medicare data; this linked SEER-Medicare database has been used by a number of investigators to explore the patterns of care for a variety of malignancies. Studies utilizing this database have confirmed on a population scale the results of controlled clinical trials that demonstrated the survival advantages of adjuvant therapy for colon and rectal cancer, surgical and chemotherapy management of lung cancer, and chemotherapy for advanced ovarian cancer8-13 (Neugut et al, manuscript submitted for publication). In an earlier article, Earle et al13 used these SEER-Medicare data to study systematically the use of chemotherapy in advanced non–small-cell lung cancer (NSCLC). They found that only about a quarter of NSCLC patients of Medicare age received chemotherapy for this disease despite a small survival advantage with chemotherapy.14 The improvement in survival was remarkably close to earlier estimates from a meta-analysis reported by the Non–Small-Cell Lung Cancer Collaborative Group.15 In the current issue of the Journal, Earle et al16 now investigate whether patients with advanced NSCLC were referred to medical oncologists. They find that 73% of these patients were referred to a medical oncologist, although only 26% ultimately received chemotherapy. Of nonmedical factors, level of education, income, and race played significant roles in whether a patient with advanced NSCLC was referred to a medical oncologist. It is worth considering the context in which they have explored referral to a medical oncologist. The investigators intentionally selected advanced lung cancer as their model because the potential benefits are small, and thus treatment decisions are especially difficult. They argue that in this setting an expert’s opinion is crucial. In contrast, Siminoff et al17 explored referral in the context of surgically resected breast cancer, a more treatable and clear-cut set of circumstances, and found that only 13% of patients were not referred to a medical oncologist. In medical oncology, as opposed to other medical subspecialties, the vast majority of referrals are for the purpose of decisions regarding therapy rather than for diagnostic purposes. Therefore, referral to a medical oncologist might be expected to depend on the perception of the success of a given therapy. Thus, breast cancer, which is widely recognized as a treatable disease, would clearly merit a higher likelihood of referral than metastatic NSCLC, which, despite the small benefit observed in Earle et al’s recent study,14 remains a rapidly fatal malignancy. Even for patients who do not have a promising therapeutic intervention available, the medical oncologist’s purview has expanded into palliative care, including pain control and symptom management, as well as terminal care. Patients with advanced NSCLC will almost always progress to require that type of care. To support this, most oncology journals and societies have increasingly included sections focused on this aspect of care. What other factors play a role in decisions regarding referral? Close to 43 million people in the United States are uninsured. Others are underinsured, disadvantaged in other ways, or, for whatever reason, have chosen not to sign up for government programs. These people are not counted in the SEER-Medicare database and are unlikely to receive appropriate medical care, let alone oncology treatments. Clearly, insurance is not the only factor leading to barriers in cancer care. Even in settings where insurance and medical care are equally available, those who are less educated, poorer, or of lower socioeconomic status are less likely to receive appropriate referrals.18,19 Since patients in these studies were selected to have some form of insurance, such as Medicare, all of them should have had equal access to referrals and therapy. Earle et al are to be congratulated for addressing some of these issues, and databases such as SEER and Medicare can direct our research efforts. For example, are the major barriers the attitudes and behaviors of the patients or those of the physicians? We have already noted some of the patient-specific factors that influence referral. Numerous studies have also suggested that physician recommendations and referrals can be crucially important factors in the receipt by patients of tests and treatments.20,21 Future studies that interview individual patients and obtain data from individual medical records are necessary to define these issues with more precision. Perhaps the most important point raised by Earle et al16 is that therapeutic nihilism must no longer be acceptable among surgeons and primary care physicians when it comes to the management of malignancies, even solid tumors. Daily, we are developing newer and more effective therapies. Whether for standard therapy, for entry onto clinical trials, or for palliative care and symptom management, these patients deserve to have their options fully investigated and explicated through the mechanism of referral. REFERENCES 1. Wolmark N, Colangelo L, Wieand S: National Surgical Adjuvant Breast and Bowel Project trials in colon cancer. Semin Oncol 28: 9-13, 2001 (1 suppl 1)[Medline]
2.
Wolmark N, Wieand HS, Hyams DM, et al: Randomized trial of postoperative adjuvant chemotherapy with or without radiotherapy for carcinoma of the rectum: National Surgical Adjuvant Breast and Bowel Project Protocol R-02. J Natl Cancer Inst 92: 388-396, 2000 3. Fisher B, Redmond C: Systemic therapy in node-negative patients: Updated findings from NSABP clinical trials—National Surgical Adjuvant Breast and Bowel Project. J Natl Cancer Inst Monogr 11: 105-116, 1992 4. Fisher B, Redmond C: Lumpectomy for breast cancer: An update of the NSABP experience—National Surgical Adjuvant Breast and Bowel Project. J Natl Cancer Inst Monogr 11: 7-13, 1992 5. Enneking WF: An abbreviated history of orthopaedic oncology in North America. Clin Orthop May:115-124, 2000 6. Klastersky J, Paesmans M: Response to chemotherapy, quality of life benefits and survival in advanced non-small cell lung cancer: Review of literature results. Lung Cancer 34: 95-101, 2001 (suppl 4) 7. Potosky AL, Riley GF, Lubitz JD, et al: Potential for cancer related health services research using a linked Medicare-tumor registry database. Med Care 31: 732-748, 1993[Medline]
8.
Bach PB, Cramer LD, Schrag D, et al: The influence of hospital volume on survival after resection for lung cancer. N Engl J Med 345: 181-188, 2001 9. Sundararajan V, Grann VR, Jacobson JS, et al: Variations in the use of adjuvant chemotherapy for node-positive colon cancer in the elderly: A population-based study. Cancer J 7: 213-218, 2001[Medline] 10. Sundararajan V, Mitra N, Grann VR, et al: Survival associated with 5-fluorouracil-based adjuvant chemotherapy among elderly patients with node-positive colon cancer. Ann Intern Med (in press)
11.
Sundararajan V, Hershman D, Grann VR, et al: Variations in the use of chemotherapy for elderly patients with advanced ovarian cancer: A population-based study. J Clin Oncol 20: 173-178, 2002 12. Klabunde CN, Potosky AL, Harlan LC, et al: Trends and black/white differences in treatment for nonmetastatic prostate cancer. Med Care 36: 1337-1348, 1998[CrossRef][Medline]
13.
Earle CC, Venditti LN, Neumann PJ, et al: Who gets chemotherapy for metastatic lung cancer? Chest 117: 1239-1246, 2000
14.
Earle CC, Tsai JS, Gelber RD, et al: Effectiveness of chemotherapy for advanced lung cancer in the elderly: Instrumental variable and propensity analysis. J Clin Oncol 19: 1064-1070, 2001 15. Chemotherapy for non-small cell lung cancer: Non-small Cell Lung Cancer Collaborative Group. Cochrane Database Syst Rev 2:CD002139, 2000
16.
Earle CC, Neumann PJ, Gelber RD, et al: Impact of referral patterns on the use of chemotherapy for lung cancer. J Clin Oncol 20: 1786-1792, 2002 17. Siminoff LA, Zhang A, Saunders Sturm CM, et al: Referral of breast cancer patients to medical oncologists after initial surgical management. Med Care 38: 696-704, 2000[CrossRef][Medline] 18. Dunlop S, Coyte PC, McIsaac W: Socio-economic status and the utilisation of physicians’ services: Results from the Canadian National Population Health Survey. Soc Sci Med 51: 123-133, 2000 19. Hargraves JL, Cunningham PJ, Hughes RG: Racial and ethnic differences in access to medical care in managed care plans. Health Serv Res 36: 853-868, 2001[Medline] 20. Fox SA, Roetzheim RG, Kington RS: Barriers to cancer prevention in the older person. Clin Geriatr Med 13: 79-95, 1997[Medline]
21.
Siminoff LA, Zhang A, Colabianchi N, et al: Factors that predict the referral of breast cancer patients onto clinical trials by their surgeons and medical oncologists. J Clin Oncol 18: 1203-1211, 2000
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Copyright © 2002 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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