As an entering freshman Penn medical student a few years back, I was ravenous to read something clinical in my spare time and soon obtained a student subscription to JAMA. Unfortunately, only the ads and physician obituaries (with listed causes of death) were understandable, though I was reassured that most docs seemed to die in their eighties.

Then, in the midst of somnolent classes in neuroanatomy and biochemistry, I chanced upon a tiny journal that changed everything. Published by the American Cancer Society, CA: A Cancer Journal for Clinicians was approachable, understandable and made sense to my virgin clinical brain.

The best part of this unique periodical was the annual “Cancer Statistics” paper that estimated (and still does) the incidence and mortality of different tumor types, along with age, gender, racial and geographic subsets and trends over time. To this day, in a weird way, the popularity of the annual CA paper reminds me of the fascination some of us feel studying sports statistics or stock market numbers.

However, the demographics of cancer tell an important story with enormous human and research implications, and in this issue of Patterns of Care, we attempt to contribute to the understanding of medical oncology practice as a clinical entity by asking 150 randomly selected US-based medical oncologists how they spend their office time. The results offer important insights with obvious and not-so-obvious implications.

We asked these physicians, and 51 clinical investigators whose practices consist of more than 75 percent breast cancer patients, to estimate the number of their new patients and office visits focused on specific tumor types — further segmenting the visits related to the adjuvant and metastatic settings. Here are a few nuggets from these queries:

Breast, colorectal and lung cancer currently make up about two thirds of medical oncology practice
(Figure 1).

These visits are roughly split equally between the adjuvant and metastatic settings. Although this is not entirely surprising, if you add in lymphoma and prostate cancer, that pretty much is today’s practice of medical oncology. I am not sure that CA or any other source provides the same picture.

In that respect, it is interesting to consider that adjuvant therapy for breast, colorectal and lung cancer make up approximately one third of medical oncology practice.

Although the agents and regimens differ for each tumor type, from a number of perspectives, adjuvant therapy could be viewed as a sub-subspecialty. All of these patients are rolling the dice by receiving adjuvant systemic therapy, in that many are cured by local therapy alone and others experience cancer recurrence in spite of receiving adjuvant treatment — a profoundly disheartening day at any oncology clinic.

Another thread linking this trio of tumors is Peter Ravdin’s Adjuvant! Online website, which spits out numbers for all three cancers that docs in practice utilize religiously in making recommendations.

Note that breast cancer represents more than a quarter of medical oncology practice despite being responsible for only seven percent of all cancer mortality. Whereas screening mammography has clearly resulted in downstaging the disease, until the recent advent of the Oncotype DX™ assay, adjuvant chemotherapy was a very likely part of the breast cancer experience for the vast majority of patients, even those with small, node-negative lesions. This helps in some part to explain the high rate of breast cancer traffic at oncology offices.

For many discouraging reasons, however, prostate cancer, which causes almost as many deaths as breast cancer — and one helluva lot of morbidity — is far less a part of an oncologist’s normal day. Also, whereas medical oncologists in practice deal with an increasingly complex menu of adjuvant options in breast cancer, prostate cancer is much more straightforward to sort out because urologic oncology investigators have yet to complete a single randomized study of adjuvant chemotherapy. (Don’t get me started.)

Note also that the vast majority of people with breast, colon and lung cancer are being seen in the community setting. This is not thyroid cancer or obscure lymphomas that are concentrated in tertiary care centers. Breast, colon and particularly lung cancer are in substance the reason people die of cancer in medical oncology practice in this country.

It is highly frustrating to consider that tens of thousands of these patients in oncology practices would be very interested in clinical trial participation, but it is often not offered because remuneration does not cover the expenses physicians incur as part of this process.

Maybe Lance Armstrong can marshal some troops to camp out on Pennsylvania Avenue and not leave until docs in practice at least break even financially with clinical trial participation. It’s way past time to express outrage about this absurd situation. Another interesting aspect of this practice snapshot is that in some cases, docs in practice may have an advantage over specialists.

Because oncologists in practice treat patients with different tumor types, they may be exposed to new agents earlier. Bevacizumab is the perfect example (Figure 2). Most practicing oncologists have much more experience with this fascinating anti-angiogenic agent than their research-based breast cancer colleagues, having used it for a couple of years in colorectal cancer, granted at a different dose
(Figure 2).

While bev isn’t necessarily complicated to administer, it does have its own unusual set of safety issues, and it is interesting to consider that for a change, breast cancer investigators might actually learn a few things from practicing oncs.

Final comment: If by chance this publication happens upon the desk, lap or LCD of a freshman medical student looking to read something clinical that is understandable, here are a few closing words just for you:

Cancer medicine is where it’s at in 2007. The field has become the critical crucible in medicine, and we need a new generation of soldiers to assist in this desperate fight. So if you exude creativity, scientific genius or compassion, quickly transition through the archaic rite of passage we call medical school and sign up with our oncology team.

Most everything else in medicine is cut and dry or comes close. Our stuff is complex, mystical and pretty much unexplained, and the tools physicians currently have available to combat this merciless disease are suboptimal to say the least.

At a deeper human level, it is also critical to remember that statistics like those in this survey are but the superficial face of what is otherwise often a desperate and highly stressful clinical situation. To better understand the current practice of medical oncology, my YouTube-text message-iPod-MySpace friends, consider our day-in-the-life portrait of Dr Allan Freedman, who is part of a seven-oncologist group in the suburbs of Atlanta (Figure 3).

As is clearly evident by his patient list of April 17, 2007, Dr Freedman and his support staff face clinical challenges that demand all they have and more. You can complain about how clinical medicine has become too “cookie cutter” or how technology has removed the human element from patient care, but sitting with a terrified patient who braved adjuvant chemotherapy only to develop recurrent disease is as emotionally raw and real as it gets, and Dr Freedman and his colleagues confront such desperate situations many times each day.

This must change. We must have better news to deliver to patients, and this can only happen through accelerating the pace of clinical research so that some day oncology clinics will consist of patients who can be cured with simple and nontoxic interventions.

Neil Love, MD
NLove@ResearchToPractice.com
June 1, 2007

SELECT PUBLICATIONS

Jemal A et al. Cancer statistics, 2007. CA Cancer J Clin 2007;57(1):43-66. Abstract

Love N; Research To Practice. Management of breast cancer in the adjuvant and metastatic settings. Patterns of Care in Medical Oncology 2007;4(1). Available at: www.PatternsOfCare.com

(New patient) 55 y/o man with prostate Ca, PSA 4.7, Gleason 6, equivocal bone scan

ALLAN FREEDMAN, MD

DR FREEDMAN: This new patient with prostate cancer turned out to be a challenging case for me. Every time I see a new patient, there’s a level of anxiety because the data must be collected and reported in a way that’s legible and followable, and so it takes a lot of time, and it sometimes turns out to be a head scratcher, as this one was. This young man was very confused. I was the tiebreaker — he had been to see a urologist who recommended radical prostatectomy and a radiation oncologist who had recommended radiation therapy, and he didn’t know what to do. I reviewed the bone scan. He had increased uptake in the sacrum and ribs, and plain films of those areas didn’t show anything. I recommended that he go ahead and have a radical prostatectomy.

DR LOVE: What made this case such a challenge?

DR FREEDMAN: First of all, this is not something that I do on a routine basis. I do see a few patients with prostate cancer who come to see me for an opinion to break a tie between a surgeon and a radiation oncologist, but it’s not what I would consider my area of expertise, and I find that to be stressful because I’m not as conversant in that literature.

• 82 y/o man with 2 metachronous colon cancers (S/P adjuvant chemo being followed)

• 64 y/o man with metastatic colon Ca on irinotecan, bevacizumab and cetuximab

• 69 y/o woman with a remote history of B-cell cancer with AIHA follow-up

42 y/o woman with metastatic breast Ca, for hospice

DR FREEDMAN: This is one of those sad stories — primary refractory metastatic breast cancer — and even though we always talk about how commonly we see responses, not everybody does respond. I’ve been treating this young woman for two years, and on this visit, I recommended that we switch to hospice care. It was a very tough visit because we’re victims of our own success and always think that we can pull out a response. But this woman has never had a response to anything. She is very ill with symptomatic brain metastases, anisocoria and painful liver metastases. She has a very supportive husband and two young children, and both the patient and husband became tearful during this discussion, but I told them that I would still be her doctor, and we would work on her comfort, but we were going to redirect our priorities.

DR LOVE: Did you find yourself thinking about this woman later that day after clinic?

DR FREEDMAN: Yes. Of course.

DR LOVE: How do you cope with those feelings?

DR FREEDMAN: I’m a long-distance bike rider, and I also work out in the gym. I also play tennis. I exercise virtually every day. That day I worked out in the gym. I was pretty tired when I first got there, but once I started working out, the energy came back.

I also have a pretty strong spiritual life, and that gives me a lot of support to get through the day, too. I go to synagogue three times a week. I also study religious philosophy with a group, and in fact, we had a telephone conference this morning, and I found that very helpful.

• 82 y/o woman with metastatic colon Ca, S/P capecitabine + oxaliplatin/bevacizumab on treatment break

• 81 y/o woman with breast Ca on adjuvant anastrozole

• 65 y/o man with Stage IV NSCLC, S/P paclitaxel + carboplatin, S/P pemetrexed, discuss 3^rd line

80 y/o man with breast Ca, finished 5 years of tamoxifen, discussed letrozole

DR FREEDMAN: This is a very active 80-year-old man who has been on tamoxifen for five years and is now considering an aromatase inhibitor. He’s married, and he and his wife are from Jamaica in the West Indies. I like seeing this man and enjoy talking with him. His wife has been ill recently and he’s been concerned about her, but he tries to be as active as possible. He’s really making an effort to have a meaningful life in his later years.

• 78 y/o man with myeloma relapse on lenalidomide/dexamethasone

• 80 y/o woman with a history of ovarian Ca treated with paclitaxel/carboplatin, now with dementia

• 39 y/o woman with metastatic pancreatic Ca on erlotinib + gemcitabine

64 y/o woman with new metastatic breast cancer starting fulvestrant

DR FREEDMAN: This lady was actually on the adjuvant capecitabine trial and then received an aromatase inhibitor. Two years later she had hip pain, and her orthopedic surgeon said, “Well, you have arthritis of your hip, and you’re going to need hip surgery.” But after the hip surgery, she wasn’t any better, and so he did a revision and it still wasn’t better. So she went to see another orthopedic surgeon for a second opinion, and he did an x-ray and she had a big lytic lesion in the head of her femur. In addition to that, she had a bone scan that showed increased uptake in the sternum, and she had a sclerotic lesion of the sternum, and last week we did an FNA of the sternum that showed metastatic adenocarcinoma. During this visit, I informed her about the biopsy results. At that point I sent her back to surgery to have a total hip replacement and post-op radiation, and I’m starting her on fulvestrant.

DR LOVE: Who came with her to the office and what was it like when you told her the biopsy results?

DR FREEDMAN: She came with her husband and daughter. They were pretty much resigned to what was going on. I had laid the groundwork before the biopsy, and so they were aware of what it was likely to show.

• 58 y/o woman with CLL, no rx

• 80 y/o woman with a history of lymphoma of the breast, history of ampullary Ca, S/P Whipple, chemo + XRT

56 y/o woman with second primary HER2+ breast Ca, 1 year S/P finishing adjuvant trastuzumab

DR FREEDMAN: This young woman is a kindergarten teacher. I had treated her years ago with CMF for her first breast cancer and this was a second primary, which was HER2-positive disease, and she received AC paclitaxel. Then, just as she was finishing that, the adjuvant trastuzumab data came out. In fact, we had even had her port removed, and I told her that I would really like to put it back in and start a year of trastuzumab, and so she did a year of trastuzumab, and since then I’ve just been following her off therapy. She’s doing great.

• 61 y/o woman with NSCLC, S/P paclitaxel, carboplatin and bevacizumab, now on maintenance bevacizumab

• 63 y/o man with second melanoma in follow-up

• 25 y/o woman with Hodgkin’s S/P Adriamycin^®, bleomycin,vinblastine and dacarbazine for follow-up

60 y/o man 5 years after BMT for mantle-cell lymphoma, now with T-cell ALL

DR FREEDMAN: This was a very stressful visit for both the patient and me. When I first saw this man five years ago, he was extremely nervous because he had Stage IV Mantle Cell, and we treated it with hyper C-VAD. He then went for transplant, and he’s been in remission for five years. He came in for a routine visit last week, and we picked up that he had pancytopenia. I was very upset about that because, as I said, “There’s no reason for you to have pancytopenia that’s good.” We did an emergency bone marrow that day and he was coming back this day to learn the results. It was a T-cell ALL.

DR LOVE: What was his reaction?

DR FREEDMAN: He was totally devastated. After his transplant five years ago, he had actually come to my office, and he said his marriage was breaking up and he was going to commit suicide. He was in remission at that time, and I drove him to a psychiatric facility myself. This man has poor coping skills, and I don’t know how he’s doing with his induction for the leukemia now, but it’s a devastating situation.

• 82 y/o woman with a history of breast Ca + NHL