A recent article in the Wall Street Journal reported that oncologists treating newly diagnosed colon cancer patients often do not comply with recommended protocols. The article examined the issue of how to evaluate physicians who treat cancer patients. According to a report by UnitedHealthcare, some patients with colon cancer receive tests and treatments that they shouldn’t, and others don’t get the recommended treatments. The evaluation by UnitedHeathcare was part of a larger study to analyze the cost effectiveness of a variety of cancer treatments for breast, lung and colon cancer.
But for newly diagnosed colon cancer patients, the article also raises concerns about how to be sure that they are receiving optimal care. At the time of diagnosis, very few patients are familiar with protocols or research into the best treatment of their disease. Simply navigating the complex abundance of information can be overwhelming. In an effort to empower patients, noted oncologist Neal Meropol sat down with GetYourRearinGear.com to discuss the Wall Street Journal report, and to provide suggestions on how patients can work with their physicians to receive the best possible care.
A much sought-after speaker, Dr Meropol is extensively published on topics that include gastrointestinal cancer therapeutics, patient decision making, healthcare economics, and bioethics. In addition to his work in developing clinical trials for patients with gastrointestinal cancer, Dr Meropol conducts research in patient decision-making and doctor-patient communication, with particular interest in barriers to clinical trial participation. Currently, Neal Meropol is Section Chief in Medical Oncology at University Hospitals Case Medical Center & Case Western Reserve University and Associate Director for Clinical Research at Case Comprehensive Cancer Center, in Cleveland, Ohio. After completing his undergraduate work at Princeton, Dr Meropol earned his medical degree at Vanderbilt Medical School and completed his fellowship in Hematology and Oncology at the University of Pennsylvania. Dr. Meropol serves on several national committees, including the NCI Colon Cancer Task Force (Chair), ECOG Developmental Therapeutics Committee (Chair), the ASCO Cancer Research Committee (Chair-elect), and the ASCO Cost of Care Task Force.
Get Your Rear in Gear: The Wall Street Journal article reported a relatively high non-compliance rate for physicians treating newly diagnosed colon cancer patients. Should those numbers raise concerns for colon cancer patients?
Neal Meropol: The pie chart in the Wall Street Journal article suggested that ultrasound is underused in patients with colon cancer. But those data are only relevant in patients with rectal cancer. There was no explanation in the article as to the guidelines being evaluated, and thus there is potential for misinterpretation.
Get Your Rear in Gear: For newly diagnosed colon cancer patients, are there standard tests that every patient should receive? Or is testing evaluated on a case-by-case basis?
Neal Meropol: In general, we individualize treatment for each patient at the time of diagnosis. But there is a battery of tests that we generally recommend as a matter of protocol:
In addition, we recommend that all patients receive a complete exam of the colon with a colonoscopy because some patients will have more than one cancer in the colon at a time.
After surgery, patients should have a well-structured surveillance plan to detect new cancers arising in the colon, and more importantly to detect a recurrence (spread) of the original colon cancer. For patients who have been diagnosed with a new cancer, a colonoscopy is recommended one year after the initial treatment and less frequently thereafter. In patients with a strong family history of colon cancer, the frequency of colonoscopy may be every year.
Additionally, other post-surgery treatment should include a CEA blood test and a physicial exam every 3 months for the first two years, then less frequently until year five. It’s important to detect recurrences early, as some patients can still be cured, even if their colon cancer comes back in another organ, such as the liver.
“It is important to note that these are guidelines. The frequency of tests depends on the features of each particular patient.”
Get Your Rear in Gear: Are there any other tests that patients ask about after treatment?
Neal Meropol: Patients often wonder about CT scans versus PET scans after treatment. Typically we recommend that a CT scan be obtained once a year for several years in patients who are at high risk for recurrence. With regards to PET scans, in general we prefer CT scans over PET scans, although PET scans can be helpful when there is uncertainty.
Get Your Rear in Gear: What types of questions can a newly diagnosed patient ask his/her oncologist to be sure that they are receiving optimal care?
Neal Meropol: For patients who have colon cancer that has not spread to another part of the body, these are important questions to ask:
- Will I be cured?
- What is the chance that my cancer will come back?
- What schedule of tests do you recommend over the next five years?
- Do I need any additional treatment besides surgery?
- If yes, what is the benefit of that treatment and what are the side effects?
For patients who have a cancer that has spread to another part of the body, often patients and doctors don’t realize that sometimes it can be cured with aggressive surgery and chemotherapy. The key questions for those patients include:
- Can this still be cured?
- If not, why not?
Get Your Rear in Gear: When is it appropriate to get a second or even third opinion?
Neal Meropol: Colon cancer is one of the most common cancers. Therefore, most oncologists are very experienced in treating it. However, sometimes clinical trials may not be available in your community, so you may choose to seek an opinion from a provider who performs clinical trials. For patients who have to undergo a complex surgery, such as the removal of liver metastasis or rectal surgery, a patient may want to get an opinion from a center that performs many of those procedures.
“If a patient is ever uncomfortable or uncertain about the information they receive from a provider, a second opinion never hurts. But I tell my patients to get a second opinion that matters. Speak to an oncologist who specializes in the treatment of colon cancer and who conducts clinical research. There are many practices that participate in clinical trials. This is often a sign of quality for community practices.”
Get Your Rear in Gear: Are there steps that friends and family can take to help a patient in finding the best treatment for colon cancer?
Neal Meropol: A friend or family member should go with the patient to his/her appointment armed with a pen and paper. The caregiver can:
- Write out questions ahead of time
- Check off each question as it is answered.
- Ask the doctor to clarify points that might not be clear at first.
- Consider bringing a tape recorder to review the dialogue at a later date.
There is so much information at first. It’s always a good idea to take along a buddy who can help you understand and make sense out of all of this information.
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