The Juxtaposition of
Personalized Cancer Care Quality and Molecular Genomics: A Real Strategic Plan
By
Leonard Zwelling
The November 14 issue of the New England Journal of Medicine
has a remarkable juxtaposition of two editorials of relevance to MD Anderson.
The first by Huckman and Kelley discusses what the lay public
is really looking for when it seeks information about medical care. The authors
make a point that I have made many times before. Most of the public has no idea
what quality medical care looks like and has not been sufficiently educated to
make judgments with regard to medical information that makes it into the lay
press. Too much trigonometry and not enough probability and biostatistics in
high school. After all, when was the last time you took the cosine of anything?
And when are the older men going to stop writing letters to the editor about
how getting a PSA and a subsequent prostatectomy saved their lives. Maybe it
did. Maybe you didn’t need the surgery.
The
authors propose that people want to know less about whether or not the hospital
in which they may have surgery has a high or low complication rate but rather
whether or not they even need the surgery at all. If that communication is done
well, utilization of precious medical resources goes down which is the real
point of providing patients with metrics of quality (even though that cost
savings reduces someone’s income). Patients are often called clients (I hate
that) and doctors providers (I hate that even more). The real questions for
most patients are what’s in it for me and how much does it actually cost? Good
questions, both, and neither is answered by quantifying the complication rate
after cardiac by-pass surgery of all TMC hospitals, although that might be a
good idea.
To
take this to an even less expected place, the authors note the rise of health
care provision at locales that were formerly sites of low cost commerce like
Wal-Mart and CVS. The authors conclude that patients are seeking all kinds of
information about outcomes. The provider (did I really say that?) of the future
will succeed at both medicine and marketing by individualizing available
information for the needs of the highly varied clientele (I mean patients). In
other words, personalized medicine may extend well beyond gene sequencing.
Patients really want help making medical decisions akin to what they can get
from Angie’s List (which is of help).
In
the second editorial, Janet Woodcock and colleagues from the FDA discuss the
agency’s newer strategies to get drugs to people with life-threatening diseases
as fast as possible. The newest mechanism is the “Breakthrough Therapy”
designation to hasten the process of getting potentially active agents to those
in need. This is usually about targeted drugs and the current list has 10
anticancer agents on it. These drugs had to have shown some activity in real
patients prior to attaining this special designation. Of the 80 requests for such designation, 26
have been granted.
The
juxtaposition is startling. When we in oncology think of personalized medicine,
we usually think along the lines of Breakthrough Therapies that have shown
promise as agents targeting molecular abnormalities in explanted and sequenced
human tumors.
Health
services researchers may think in terms of the patient’s decision making about
whether or not to even undergo proposed therapies and how fulfilling that
patient need is best done by health care professionals who take into account
the personalization of these aspects of care, like cost and appropriateness.
MD
Anderson could do both.
Clearly,
Anderson has played a prominent role in the second type of personalized care
that is target-based. But there is nothing preventing Anderson from being the
leader in the first type of personalization as well. It would however require
an investment in outcomes measurement, cost analysis and devising instruments
to identify patient preferences BEFORE patients get to Houston for if what
Anderson is great at—cancer surgery, radiotherapy and experimental chemotherapy
as well as modern diagnostics—is neither desired by the patient nor appropriate
for the patient, perhaps that is a patient who needs to be handled elsewhere,
perhaps in a regional care center. This might allow Anderson to be more
selective in what it does clinically, reduce its huge fixed costs and actually
improve its outcomes and surely its patient satisfaction. It might even fund a
moon shot or two. Sounds like a win-win-win-win to me, but it will necessitate
as serious a development of health services research, especially health
economics and decision-making, as is being invested in moon shooting.
The current administration has retained the declaration of
MD Anderson’s clinical superiority while treating the operations part of
patient care like a giant factory. Is Anderson Tiffany or Wal-Mart? Decide, but
you cannot be both.
A more focused approach to care at 1515 integrated with
routine cancer care at other sites, a marked shrinkage of Holcombe Boulevard
fixed costs and the introduction of mechanisms to screen away patients that
Anderson cannot uniquely assist or who cannot assist the research mission by
participation in clinical trials, would be a great start toward really
personalizing total care and generating a more patient-centered environment and
a more faculty-centered mode of operating.
