A recent study by Koshy and colleagues at the University of Chicago (click here for the abstract; Dr. Stark can provide the entire article) suggests that patients with Stage 4 lung cancer are being overtreated with radiation. The standard of care for patients with metastatic disease beyond the confines of one lung and the ipsilateral mediastinum is palliative chemotherapy or just symptom control, with radiation reserved for such things as painful bone metastases and brain metastases, where most drugs don’t reach. The highly insured patients in their study were more likely to receive radiation to the chest even though it was highly unlikely it would do any good Dr. Stark weighs in: “Congratulations to the University of Chicago for doing this analysis, and for the Journal of the National Cancer Institute for publishing it. Clearly the profit motive is alive and well among what seems to be a large minority of the Radiation Oncology community. This is disappointing but not entirely surprising. What is sad is that dollar signs come into play, and some patients are actually harmed by the side effects from radiation where there was no hope that this treatment would allow them to live longer or better quality lives. Maybe these physicians can be shamed into more ethical practice patterns.” Sadly Medicare, the most common payor for patients with cancer, does a poor job of monitoring utilization of scarce and expensive resources; maybe now there will be social pressure for them to do more.
Update 2020: the pattern continues. In 2016 a careful study done regarding treatment patterns for rectal cancer was published in the journal CANCER. The authors found that in the US radiation oncologists favored long-course radiation over short course without any additional benefit seen for the patient. When queried fully 20% admitted that reimubursement was the driving factor. Interestingly, only 11% of the large group of radiation oncologists surveyed even bothered to respond to the inquiry. Dr. Stark comments, “What ever happened to the Hippocratic Oath?” Patients are being victimized in the name of profit. What is different here is that only a small percentage of doctors wasf even willing to be questioned about this issue, and fully 20% of those who agreed to answer the questionnaire admitted to greed as a driver of decisions.