The crisis in health care cost in the United States: some implications for radiation oncology.

This communication reviews the increasing cost of medical care in the USA (13% of GNP in 1995) and the associated lack of access to care for 35 million citizens. Factors affecting cost and access are presented, including where the increases are seen. The resulting effects on the Federal government, private industry, the patient, and the physician are noted. The failure of a current mechanism of control of cost is illustrated as are the views of patients and physicians. The portion of radiation oncology devoted to palliative care is discussed for its potential to reduce costs by $150-$250 million through the elimination of excessive treatments and thereby contribute to the solution of excessive cost of care.     

Truth-telling to cancer patients in the western european context

The meaning and the practice of truth-telling have undergone many changes throughout western European history. Although Plato noted the conflict between the idea of protecting individuals from information which could frighten them and the idea of respecting their autonomy and freedom to know, Greek physicians displayed a more pragmatic attitude. In contrast, the Catholic church has always condemned any form of lying. The emergence in the Middle Ages of the notion that Catholics had to receive the sacrament of extreme unction in order to ensure salvation made it necessary to inform patients of the approach of death. But the gradual decline of the Church's influence since the eighteenth century led to the increasing practise of telling medical ‘white lies’. Rapid changes are occurring, however, in light of medical progress, evolving ethical beliefs and major sociological changes, especially the increasing role of the media. In fact, the medical ‘secret’ is shared by many people and the problem is no longer whether physicians must tell the truth but how to tell it. Patients often do not understand the information they are given because the words are too esoteric. Failures in physician/patient communication arise also because of the phenomenon of denial, which is a part of the normal adaptation process. The physician has the responsibility of making the decision and of imparting to the patient a sense of innovation and progress.     

Evaluation of three cervical cancer detection programs in Japan with special reference to cost-benefit analysis

Three screening programs for early cervical cancer currently in use in Japan were evaluated according to the following criteria: (1) economic effectiveness; (2) screening efficiency; and (3) access to medical care. The mobile program has the highest benefit-cost ratio (BCR, 1.20) and is hence most cost-effective; its detection rate, rescreening rate, and early cancer detection rate (proportion of Stage-O patients to all patients with cancer) are moderately high (0.09%, 2.07%, 55%, respectively). It is obviously suited to rural areas, especially where residents have a positive attitude toward local health services. The detection center program is less cost-effective than the mobile program (BCR, 0.83) but diagnostically the most effective with highest detection, rescreening, and early cancer detection rate (0.15%, 5.08%, 61%, respectively). It is suitable to large cities (population over 1 million) with efficient public transportation. The private physician program is economically and in terms of screening efficiency least effective of the three; its BCR being 0.40 and detection, rescreening, and early cancer detection rate being the lowest (0.08%, 0.29%, 33%, respectively). However, the private physician program is increasingly employed, presumably because of easy access to medical care, better rapport between the patient and physician, and, in addition, successful lobbying by private physicians.     

Prevalence of Cancer Visits by Physician Specialty, 1997–2006

Understanding the prevalence of cancer-related visits by physician specialty may help target educational and quality improvement initiatives. Using the 1997–2006 National Ambulatory Medical Care Survey, adult ambulatory visits (N = 161,278) were classified by cancer diagnosis and patients’ characteristics and compared with physician specialty. The prevalence of cancer visits within each specialty varied from 0% to 62%. Aside from hematology/oncology (hem/onc) specialties, nine surgical specialties and four medical specialties had more than 1% cancer visits. Cancer patients with private insurance or Medicaid coverage were less likely to see hem/onc specialists compared to Medicare patients. Whereas hem/onc specialists primarily see cancer patients, general surgeons and primary care physicians provide a large amount of cancer services, particularly to underinsured patients. Thus, when trying to contact cancer patients or their physicians, health administrators, researchers, and practitioners should consider targeting general surgeons and primary care physicians in addition to hem/onc specialists.     

Clinical trial discussion, referral, and recruitment: physician, patient, and system factors

Purpose

Patient participation in cancer clinical trials is imperative to the advancement of medical science. Physicians play an important role in recruitment by discussing clinical trials with their cancer patients. Patient–physician discussion is influenced by many factors relating to the physician, the patient, and the healthcare system.

Methods

Physicians selected from the 2008–2009 American Medical Association Physician Masterfile who practiced in California, Florida, Illinois, or New York and specialized in medical oncology, surgery, or radiation oncology were surveyed about their attitudes and practices with respect to breast cancer clinical trials. Practice types were categorized according to the classifications provided by the American College of Surgeons, and clinical trial and practice addresses were geocoded.

Results

Surveys were completed by 706 of 1,534 eligible physicians (46 %). Medical oncologists were more likely than surgical or radiation oncologists to discuss the possibility, benefits, and risks of clinical trial enrollment with their breast cancer patients. Physicians who spent the most time in patient care were least likely to discuss clinical trials with their patients. Distance from a physician’s practice to the nearest clinical trial site was inversely associated with referral and recruitment. Perceived barriers to clinical trial participation were associated with greater referral activity suggesting that physicians who were more involved in trials were also more likely to understand barriers to participation.

Conclusions

Multilevel interventions may be successful at increasing participation of women in clinical trials.     

Controversies and consensus in the innovation access for cancer therapy in the European countries: on the subject of metastatic prostate cancer

Innovative cancer therapies and advances in drug development have created new hopes for patients and health providers. The purpose of this article was to evaluate the discrepancies in the assessment of the magnitude of benefit of four new drugs (abiraterone acetate, enzalutamide, cabazitaxel, radium-223 dichloride) for the treatment of metastatic castration-resistant prostate cancer (mCRPC). The comparison was done among three European countries (UK, Germany and France) and Canada, according to the statement of each country and to the European Society of Medical Oncology (ESMO) Magnitude of Clinical Benefit Scale. Whereas those drugs are authorized by the European Medical Agency, one can observed that clear discrepancies in the magnitude of benefit assessment exist between selected countries, as well as between national pricing evaluation agencies and ESMO. However, price setting and reimbursement decisions remain national responsibility with differences in assessment of the medical value of new treatment across countries, leading to a heterogeneous accessibility to cancer treatments. In conclusion, several procedures have to be implemented to overcome the patchwork of administrative assessments. Among them, the assessment of medical value should be based on independent statements of learned societies, and the harmonization of access to cancer therapy in Europe has to be driven by a common European reimbursement and pricing policy.     

放射肿瘤学专业住院医师规范化培训初步实践与思考

放射肿瘤学专业具有本科教学无相关课程、学习内容难、覆盖病种多、与内外科明显不同的特点。放射肿瘤学专业2014年被国家纳入住院医师规范化培训的科目。如何做好放射肿瘤学专业住院医师规范化培训是一个全新命题。依据自身特点,除了采用带教老师负责制,还创新使用指导导师负责制。从临床实践能力、临床思维能力、科研能力和教学能力等多方面对住院医师进行全方位、系统化、规范化的培训,并通过各项规范化的考核制度,保证住院医师的培训效果。本文同时对放射肿瘤学专业住院医师规范化培训中存在的问题及相应对策进行初步探讨。     

Practicing in Partnership With Dr. Google: The Growing Effect of Social Media in Oncology Practice and Research

A significant proportion of patients and caregivers without formal medical training are turning to Internet-based educational and support resources as they search for relevant and reliable content. Through these efforts, many patients are becoming engaged in learning about their treatment options, including clinical trial opportunities, from outside sources. This editorial discusses the potential beneficial and detrimental effects of the disruptive influence of online information and support on the relationship between patients and physicians.Oncology is in the midst of transformation on several fronts. Anatomically defined diagnoses are being reclassified into molecularly defined subsets. A growing proportion of community-based oncologists are becoming employees of hospitals that are now increasingly becoming aligned into large networks covering broad geographic territories. The growing momentum of telemedicine is beginning to confer the possibility to deliver specialty and even subspecialty care to patients who would otherwise not have such ready access to it.Along with these significant changes, access to information has been fundamentally altered by the Internet. For the first time, a significant proportion of patients and caregivers without formal medical training are turning to Internet-based educational and support resources as they search online for relevant and reliable content. Through these efforts, many patients are becoming engaged in learning about their treatment options, including clinical trial opportunities, from outside sources. As is the case with any profound change, there are potential beneficial and detrimental effects of the disruptive influence of online information and support on the relationship between patients and physicians, as well as on the conduct of clinical research in a new era of molecular oncology.     

Discussion of fertility preservation with newly diagnosed patients: oncologists’ views

Introduction Although physician discussion with patients regarding fertility preservation (FP) options prior to cancer treatment can provide important information for survivors concerning their future fertility, little is known about the extent to which physicians discuss FP with patients. This qualitative study sought to identify current physician FP communication practices and determine factors that may impact communication efforts regarding FP. Materials and methods Qualitative data were collected using semi structured interviews with 16 physicians practicing at a major cancer center in the South. Results All providers were board certified in medical oncology, radiation oncology or surgical oncology. The main factors that emerged from qualitative analysis included distinct variations in quality of discussion about FP, knowledge of FP resources, attitudes, practice behaviors and perceptions of patient characteristics. Discussion While most physicians discussed potential fertility loss as a side effect of cancer treatment, few provided information to patients about preserving fertility. Patient characteristics such as gender and cancer site may impact the discussion, as well as system factors such as costs of procedures and access to FP resources. Education and training for physicians about FP options for cancer patients, particularly females, may promote discussion of FP. In addition, system barriers related to availability and affordability of FP resources must also be addressed. Implications for cancer survivors Physicians should consider providing patients with timely, understandable information related to their FP options, prior to the administration of treatment. Such discussions may lead to improved quality of life for individuals as they transition from patients to survivors.     

An Achievement of Professional, Public, and Patient Education: The Design and Evaluation of a Comprehensive Cancer Control Plan for Alabama

This Alabama statewide cancer control plan for 2011-2015 seeks to build on the successes of two previous 5-year plans while developing new objectives that address cancer disparities and cancer prevention over the entire lifespan. The approach to defining objectives for this Plan was systematic and sought input from all members of the Alabama Comprehensive Cancer Control Coalition (ACCCC). The Plan that was fashioned is based on input from academic medical centers, private physicians, government agencies, regulatory agencies, health societies, private citizens, and cancer survivors, all of whom are active Coalition members who exchange information, opinions, and knowledge from their respective points of view. The Plan could not have taken shape without the full input of health professionals, statisticians, graduate students, former patients, and concerned citizens; it is truly an example of the synergy of professional, public, and patient education.     

Reimbursement for surgical procedures in gynecologic oncology

Reimbursement for gynecologic oncologists can be categorized into three areas: payments for evaluation and management of clinical diagnosis, payments for chemotherapy, and reimbursement for surgical procedures. Revenue from surgical care is generally considered the major source of income for gynecologic oncologists. The transition to Medicare's resource-based relative value scale-based physician payment system began on January 1, 1992, culminating nearly a decade of effort by the medical profession and the government to change the way Medicare pays for physician services. The resource-based relative value scale payment schedule was fully phased in on January 1, 1996, and has been adopted by other third party payers. As a result of this reform, relative value units were created for current procedural technology codes and represent a composite of work, practice, and malpractice expenditures. When multiplied by a dollar conversion factor, relative value units can be used to calculate the reimbursement amount for all procedures covered by Medicare and other private insurers. Many of the discrepancies in reimbursement for similar procedures performed by gynecologists and urologists were partially corrected in 1997; however, sex-specific bias still exists in payment for surgical procedures performed on men and women.     

Early market access of cancer drugs in the EU

Patient access to new cancer drugs in the EU involves centralised licensing decisions by regulators as well as reimbursement recommendations in the context of national healthcare systems. Differences in assessment criteria and evidence requirements may result in divergent decisions at central and national levels, ultimately compromising effective access to patients. Early access decisions are particularly challenging due to the limited clinical evidence available to conclude on the benefit–risk and relative (cost-) effectiveness of new high-priced cancer drugs. We describe mechanisms to accelerate approval of promising anticancer drugs that fulfil an unmet medical need, review the experience from the European Medicines Agency, compare timelines and outcomes of reimbursement decisions in major EU markets, and discuss shortcomings of the current system, ongoing initiatives, and future steps to facilitate effective early access.     

A population-based study of the prevalence and influence of gifts to radiation oncologists from pharmaceutical companies and medical equipment manufacturers

PURPOSE: Hospital-based physicians are responsible for the purchase of expensive equipment. Little is known about the influence of gift giving on their behavior. We wanted to ascertain the prevalence of gift giving from the pharmaceutical industry and medical equipment manufacturers to radiation oncologists and determine whether or not the size of accepted gifts influences their opinions regarding gifts. METHODS AND MATERIALS: A population-based survey of hospital-based physicians conducted between 2002 and 2003. The study population consisted of all radiation oncologists who were members of the American Society of Therapeutic Radiology and Oncology between 2000 and 2001. A random number generator was used to identify 20% of the population. This group was invited by e-mail and conventional mail to complete a Likert scale questionnaire. Those asked to complete the questionnaire electronically were directed to a specially designed web site. RESULTS: Of 640 individuals who were asked to participate, 241 (38%) completed the questionnaire. 96% admitted accepting gifts. The most commonly accepted low value gifts were: pen or pencil (78%), drug samples for patient's use (70%), meal (66%), and a note pad (59%). The most commonly accepted high value gifts were trips to "equipment-users meetings" (15%), honoraria for speaking at a conference (10%), and participation in a conference call (9%). Only 5% of radiation oncologists agreed with the statement "my prescribing practices are affected" by gifts; however, 33% agreed with the statement "I believe that other physicians prescribing practices are affected." Similarly, although only 4% felt that their recommendations concerning purchases of medical equipment are affected by gifts, 19% felt that other physicians would be influenced. A test of the hypothesis that physicians believe that their conduct is less affected than those of their colleagues (i.e., "I am not influenced by gifts but someone else is" was strongly affirmed by a correlation statistic) (p < 0.0001). Of the radiation oncologists surveyed, 74% felt that they should be free to accept gifts of small value, 31% felt they should be free to accept meals or gifts of any type, 16% felt that residency programs should ban free meals provided by companies, 13% felt professional associations should discourage companies from hosting parties at the annual meeting, 17% felt that gift giving should stop, and 66% agreed that clinical information provided by companies provides a useful continuing medical education service. Those who accepted larger gifts were far more likely to disagree with statements such as "professional societies should actively discourage companies from hosting parties and providing free meals and giving gifts to physicians attending the annual meeting" (p = 0.0003) and "the practice of gift giving by companies should stop" (p = 0.0017); they were slightly more likely to agree with statements such as "clinical information provided to radiation oncologists by companies provides a useful continuing medical education service." CONCLUSIONS: To our knowledge, this study represents the first large-scale population based study of a hospital-based specialty and gift giving. This study demonstrates that: (1) Gift giving in radiation oncology is endemic. (2) Although each physician is likely to consider himself or herself immune from being influenced by gift giving, he or she is suspicious that the "next person" is influenced. (3) There is a correlation between the willingness of individual physician to accept gifts of high value and their sympathy toward this practice.     

Stakes, aims and specificities of the physician-patient communication in cancer care: state of the art and perspectives

The physician-patient relationship has three main stakes : creating a high-quality inter-personal relationship, exchanging information and decision-making. The achievement of these stakes implies that the physician and the patient are able to reach specific communicational objectives. The aim of this paper is to review the characteristics of care as regards cancer patients that could prevent the physician from reaching these stakes and objectives. Moreover, two future perspectives in this field are exposed : the study of factors that influence the communication process when a cancer patient is accompanied by one of his or her relative in a medical interview and the study of personal characteristics of physicians that can predict their ability to communicate in cancer care. On the basis of this triple review, proposals aimed to improve physician-patient communication in cancer care are exposed.     

Clinical Characteristics of Familial B-CLL in the National Cancer Institute Familial Registry

In an ongoing study, families with two or more living cases of B-CLL in first-degree relatives have been recruited through physician and self-referral. Since 1967, 28 kindreds with 73 cases of B-CLL have been enrolled within the National Cancer Institute (NCI) Familial B-CLL Registry. Medical, clinical, and demographic information have been obtained from private physicians, patient interview, hospital records, and death certificates. We used SEER Registry data to compare characteristics of sporadic B-CLL to familial B-CLL. The mean age at diagnosis was approximately 10 years younger among familial cases (57.9 × 12.1) than that observed in sporadic cases (70.1 × 11.9). A higher percentage of second primary tumors among familial CLL cases compared to reports in sporadic was also observed (16% vs. 8.8%). However, the transformation rate to non-Hodgkin's lymphoma does not appear to be different from that reported for sporadic cases. In conclusion, we observed some differences between familial and sporadic cases; whether any of these characteristics affect survival time or severity of disease is unknown. The study of families with multiple B-CLL cases will aid in delineating the genes and environmental factors that may play a role in the development of both forms of B-CLL.     

Clinical characteristics of familial B-CLL in the National Cancer Institute Familial Registry.

In an ongoing study, families with two or more living cases of B-CLL in first-degree relatives have been recruited through physician and self-referral. Since 1967, 28 kindreds with 73 cases of B-CLL have been enrolled within the National Cancer Institute (NCI) Familial B-CLL Registry. Medical, clinical, and demographic information have been obtained from private physicians, patient interview, hospital records, and death certificates. We used SEER Registry data to compare characteristics of sporadic B-CLL to familial B-CLL. The mean age at diagnosis was approximately 10 years younger among familial cases (57.9 +/- 12.1) than that observed in sporadic cases (70.1 +/- 11.9). A higher percentage of second primary tumors among familial CLL cases compared to reports in sporadic was also observed (16% vs. 8.8%). However, the transformation rate to non-Hodgkin's lymphoma does not appear to be different from that reported for sporadic cases. In conclusion, we observed some differences between familial and sporadic cases; whether any of these characteristics affect survival time or severity of disease is unknown. The study of families with multiple B-CLL cases will aid in delineating the genes and environmental factors that may play a role in the development of both forms of B-CLL.     

Medical malpractice: a review of issues for providers

The worlds of law and medicine meet in some very interesting and very important ways. Together, lawyers and physicians tackle such subjects as cloning, right to die, surrogate parenthood, and embryo preservation and implantation, to name a few. The most personal and painful nexus for physicians comes when a physician is sued and must then deal with the legal system as a defendant. The world of plaintiffs, experts, legal doctrines, state and federal law, and judicial application of law to the facts of the case can be intimidating. It is hoped that this overview has allowed the hematology-oncology practitioner to become more familiar with the theories and procedures involved in medical negligence actions. The physician, when comfortable with the basics, may better tolerate the apparent idiosyncrasies of the system and even may be able to protect him or herself from becoming involved in a lawsuit ab initio.     

Palliative radiotherapy practice within Western European countries: impact of the radiotherapy financing system?

PURPOSE: To analyze the reimbursement modalities for radiotherapy in the different Western European countries, as well as to investigate if these differences have an impact on the palliative radiotherapy practice for bone metastases. MATERIALS AND METHODS: A questionnaire was sent to 565 radiotherapy centres included in the 1997 ESTRO directory. In this questionnaire the reimbursement strategy applied in the different centres was assessed, with respect to the use of a budget (departmental or hospital budget), case payment and/or fee-for-service reimbursement. The differences were analyzed according to country and to type and size of the radiotherapy centre. RESULTS: A total of 170 centres (86% of the responders) returned the questionnaire. Most frequent is budget reimbursement: some form of budget reimbursement is found in 69% of the centres, whereas 46% of the centres are partly reimbursed through fee-for-service and 35% through case payment. The larger the department, the more frequent the reimbursement through a budget or a case payment system and the less the importance of fee-for-service reimbursement (chi(2): P=0.0012; logit: P=0.0055). Whereas private centres are almost equally reimbursed by fee-for-service financing as by budget or case payment, radiotherapy departments in university hospitals receive the largest part of their financial resources through a budget or by case payment (83%) (chi(2): P=0.002; logit: P=0.0073). A correlation between the country and the radiotherapy reimbursement system was also demonstrated (P=0.002), radiotherapy centres in Spain, the Netherlands and the United Kingdom being almost entirely reimbursed through a budget and/or case payment and centres in Germany and Switzerland mostly through a fee-for-service system. In budget and case payment financing lower total number of fractions and lower total dose (chi(2): P=0.003; logit: P=0.0120) as well as less shielding blocks (chi(2): P=0.003; logit: P=0.0066) are used. A same tendency is found for the use of isodose calculations and field set-up, but without being statistically significant (P=0.264 and P=0.061 res.). The type of the centre and the reimbursement modality influence the fractionation regimen independently (P=0.0274). This is not the case for the centre size and the reimbursement, which were found to exert correlated effects on the fractionation schedule (P=0.1042). CONCLUSION: Reimbursement systems seem to influence radiotherapy practice. One should therefore aim to develop reimbursement criteria that pursue to deliver, not only the best qualitative, but also the most cost-effective treatments to the patients.     

Clinical trials: are they a good buy?

PURPOSE: Concern that clinical trials may be too costly has been used to justify traditionally restrictive insurer policies regarding clinical trials. Additionally, fear of insurer reimbursement denial can be a significant barrier to clinical trial participation. In this study, we reviewed the empirical data on costs of clinical trials versus standard care and summarized the current status of policy initiatives related to clinical trial insurance reimbursement. METHODS: Electronic and print data sources were searched for studies on the costs of oncology clinical trials. Information on policy initiatives for clinical trial reimbursement was obtained from the American Society of Clinical Oncology, the American Society of Hematology, and the Coalition of National Cancer Cooperative Groups and from searches of World Wide Web sites. RESULTS: Five pilot studies provided information for 377 patients on phase II/III clinical trials matched with controls on standard care. Cost estimates ranged from 10% lower to 23% higher costs/charges for clinical trials in comparison to standard medical care. Medicare, 14 states, and several private insurers now cover the costs of patient care in "qualifying" clinical trials. CONCLUSION: Findings from small pilot studies suggest that phase II and III clinical trials result in at most modest increases in cost over standard treatment costs. Also, an increasing number of policy makers have decided to support clinical trial reimbursement initiatives. It is hoped that economic data from large observational studies will facilitate widespread and permanent decisions that support reimbursement for phase I, II, and III clinical trial participation.     

A cultural and global perspective of United States health care economics

Because the relative costs are so high, the healthcare system of the United States is the subject of much scrutiny, analysis, and criticism. Other countries have the same or better outcomes with significantly lower costs. Health care systems, however, are a reflection of the societies they serve. They develop over time within a framework of the collective national experience. The American approach is unique in that it has relied much more on market-based solutions to healthcare issues. This article provides an overview of the healthcare systems in Canada, Germany, and Japan. It then discusses the significant factors that drive the higher costs of the American system, starting with a review of the general aspects of Markets. American hospitals, the pharmaceutical industry, malpractice costs, private insurance, Medicare and physicians are then placed in historical context to give the reader a broader perspective of United States Healthcare Economics.