Suspect Cancer?

What the Primary Care Physician can do

Transcript

1. Suspect Cancer? What the Primary Care Physician can do Robert W Warner MD Heartland Heartland Oncology & Hematology
2. • Oncology and hematology is the diagnosis and treatment of cancers and diseases of the blood Warner; KMA radio "House Calls" October, 2011 • 82% of malignant diagnoses are made by or initiated by primary care physicians in the United States Zaconne; NCI 2009 • 85% of cancer treatment in the United States is given in community hospitals and cancer centers Okon; "House Calls" KMA radio March 2011 Suspect Cancer? What the Primary Care Physician can do
3. Patients perception of time to treatment • First symptom • First physician visit • Physician places cancer in differential diagnosis • Definitive investigation for malignancy initiated • Anti cancer treatment initiated Hamilton BJGP Feb 2, 2010
4. A (1st sx) B (MD visit) C (CA in ddx) D (CA w/u initiated) E (RX initiated) • 41% of patients with rectal bleeding reported it to their primary physician Hamilton BJGP Feb 1, 2010 {delay A->B} • June 28, 2011 Ombudsman for the west Wales Health Board, noting a patient "Mr C" had complained of having to wait for over one year following his new diagnosis of prostate cancer was quoted "The delay will undoubtedly have an impact on Mr C's prognosis, albeit to what extent is unknown-that degree of uncertainty is understandably distressing for Mr C. He has my every sympathy, and I share his concerns at the the events highlighted by his case. He has, in my view, suffered a significant injustice." {delay D->E} • 247 days is the mean time from suspicion of prostate cancer to initiation of treatment in Canada Stevens CUAJ Aug 4, 2010 {delay C->E}
5. A (1st sx) B (MD visit) C (CA in ddx) D (CA w/u initiated) E (RX initiated) • United Kingdom Cancer reform strategy 2007 1. Target waiting times in UK to no more that 2 months between an urgent primary care referral for suspected cancer and initiating of rx {delay D->E} 2. Target initiation of treatment no more than 31 days after the patient and physician have agreed on a treatment plan {delay intra E} • Heartland Oncology and Hematology goal (essentially the same standard of care to be expected from any oncology group in the midwest) ◦ Patient to be seen at next oncology clinic in outlying community - or the same or next business day if they would like to drive to our Council Bluffs office ◦ Initiation of treatment to begin when the patient wishes, and after baseline studies (e.g. MUGA scan before using adriamycin) or venous access devices are placed. Often treatment is optimally initiated on the first visit, to allay the patients fear of the unknown (FDR "The only thing we have to fear is fear itself")
6. A (1st sx) B (MD visit) C (CA in ddx) D (CA w/u initiated) E (RX initiated) • Importance of patient perception of an efficient work up Feranadez "Medically Speaking" WOW radio Dec, 1992 • Regardless of the time between the first symptoms and the first visit to a physician, patients are acutely aware of the time cancer is first entered into the differential diagnosis and initiation of treatment {C->E} • The patient perception of an inefficient work up is a leading cause for a lack of confidence and transfer of care to a tertiary center, failure to respond to treatment or dissatisfaction with actual quality of care were rare reasons to request a change. Wagner; U Penn 2008 unpublished
7. Suspect Cancer? What the Primary Care Physician can do • Iowa community hospitals provide over 70,000 jobs, with a payroll of $3.7 billion, and over 138,000 jobs are tied to Iowa hospitals, with an economic impact of $6.1 billion Iowa Hospital Association, Hospital Economic Impact report 2010 • Good health care is not only literally a matter of life and death, it is also an economic anchor and major employer in many Iowa communities. Senator Grassley; "House Calls" KMA radio Oct, 2010
8. • Liver Function Tests • Renal Parameters • Myocardial Status • Blood Counts • Tumor Markers • Flow Cytometry • Chromosomal Analysis • Familial Genetic Testing • CT Chest • CT Abdomen • CT Pelvis • MRI Cervical Spine • MRI Thoracic Spine • MRI Lumbar Spine • MRI Sacrum • CT Head • MRI Brain • Bone Scan • Bone Survey • FDG PET • Iodine-131 Scan • Tc99 Scan • Ultra Sound Orszag director of the Congressional Budget Office-Nov 7, 2008 "U S spends $700 billion on unnecessary medical tests" Suspect Cancer? What the Primary Care Physician can do
9. Orszag director of the Congressional Budget Office-Nov 7, 2008 U S spends $700 billion on unnecessary medical tests Suspect Cancer? What the Primary Care Physician can do
10. If you can’t afford a doctor, go to an airport! You’ll get a free x-ray, a breast exam and, if you mention you’re from Al Qaeda, you’ll get a free colonoscopy.
11. Appropriate use of resources • Optimal timing of necessary tests? ◦ Soon • Optimal timing of optional tests? ◦ Maybe never • “Insurance industry fails at rating physicians on cost” ◦ But the practice of actively monitoring the expense of tests ordered for a given diagnosis continues • Walker NEJM March 18, 2011 NCCN guidelines www.heartlandoncology.com
12. Appropriate use of resources • Not covered by most payers ◦ NHL pt becoming PET negative after 2 cycles =89% PFS at 5 years - complete planned # of courses ◦ NHL pt remaining PET positive after 2 cycles=16% PFS at 5 years - ergo, time to change RX MIkhaeel; Annals of Oncology, 2005 • Covered by most payers ◦ Colon cancer with no extra colonic abnormalities on CT, yield of a pre op PET virtually nil Bar-shalom; Journal of Nuclear Medicine, 2003 However NB this will ‣ Raise the cost of the workup and ‣ Delay coverage of other useful indications
13. • 10,000,000 people are living with cancer in the United States Vanderbilt 2009 unpublished • The goal of oncology in the early 21st century is to turn cancer into a chronic disease Warner; "House Calls" KMA radio October, 2011 Suspect Cancer? What the Primary Care Physician can do
14. House Calls Radio Show Sunday 9:30 am The Chuck & Don Show Tuesday 9:35 am KMA 960 AM kma960.com HeartlandOncology.com On the Radio
15. Suspect Cancer? What the Primary Care Physician can do Robert W Warner MD Heartland Heartland Oncology & Hematology