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Still Room for Improvement in Cancer Care

Five-year study shows wide range when it comes to following treatment guidelines

SUNDAY, May 15, 2005 (HealthDay News) -- A survey of cancer patients in five U.S. cities has found that cancer care is generally of good quality, but there is room for improvement.

The results, part of an intensive five-year study coordinated by the American Society of Clinical Oncology (ASCO), were announced Sunday at the society's annual meeting, in Orlando, Fla.

"Compared to quality assessments in other studies, these are remarkably high numbers," said Dr. Ezekiel J. Emanuel, chairman of ASCO's initiative on cancer care quality. One such study, published within the last year, found that general adherence to quality standards in general physicians' offices in 12 areas of the United States was only 55 percent, Emanuel said.

The ASCO survey came in response to an earlier Institute of Medicine report that questioned the quality of care in the United States.

Researchers looked at the quality of breast and colorectal cancer care by scouring detailed medical records and interviewing 2,366 patients in Atlanta, Cleveland, Houston, Kansas City and Los Angeles.

For both types of cancer, quality of care can have an impact on survival. Quality measures were assessed in five categories: diagnosis, surgery, adjuvant therapy, managing toxicities from therapy, and surveillance.

One measure of quality was whether a colon cancer patient who received chemotherapy got a dosage and number of cycles within published, accepted guidelines. Adherence to this measure ranged from 62 percent to 85 percent. For breast cancer, the range was 29 percent to 74 percent, according to the study.

Overall, quality measures were met 86 percent of the time in breast cancer, but the range was wide: from 27 percent to 100 percent.

For colorectal cancer, quality measures were met 78 percent of the time, with a range of 19 percent to 100 percent.

"Oncologists seem to be doing well, but it's quite clear that we're not doing well enough," Emanuel said. ASCO is now looking for ways to improve care, including a chemotherapy summary sheet for oncologists, he said.

"We want to make sure that every cancer patient gets the right therapy for cancer 100 percent of the time," Emanuel said.

In another survey, this one of ASCO medical oncologists, 98 percent of doctors said they were honest in communicating the nature of the disease with their terminally ill patients. But only 43 percent said they always or usually gave a time frame for remaining length of life, and then only more often if the patient initiated the discussion. Three quarters of physicians, however, said they would want this information if they were on the other side of the examining room.

At the same time, more than 90 percent of physicians surveyed said both they and their patients were satisfied with the communications, a finding that differs from past surveys of patients and their families.

"Approximately 500,000 cancer patients die each year in the U.S., indicating the importance of advanced care planning, and physicians have been described as being quite poor at giving accurate prognostic information," said study author Dr. Christopher K. Daugherty, an associate professor at the University of Chicago.

"This demonstrates medical oncologists have real ambivalence about what they should say, how they should say it and when they should say it," he continued. "There were a high number of comments where the word 'but' was used. For informed end-of-life care decisions to be made, cancer physicians and patients must acknowledge the importance of prognostic information."

Another study found vast regional differences in the number of lymph nodes removed and assessed in patients undergoing surgery for gastric cancer. While new guidelines stipulate that 15 need to be removed and analyzed, only one-quarter of patients had the recommended number assessed. The median number of lymph nodes assessed was nine, the study found.

The number of lymph nodes removed and examined was strongly correlated with survival. Twice as many patients (33.4 percent) were alive five years after diagnosis in Hawaii, where the median number of lymph nodes removed was 15, than in Utah (16.2 percent), where the median number of lymph nodes removed was only six, the study said.

Finally, another study found that black women are more likely to experience delays between screening and diagnosis of breast cancer, and between diagnosis and treatment.

Overall, 27 percent of black women had a delay, compared with about 15 percent of white women.

"Women who are black have diagnostic and treatment delays far above those of white women, Asian/Pacific Island women and Hispanic women," said study author Sherri N. Sheinfeld Gorin, an associate professor at Columbia University in New York City. "This potentially influences differences in survival."

Although white women have the highest incidence of breast cancer, black women have higher mortality rates.

More information

For more on living with cancer, visit the American Society of Clinical Oncology's People Living With Cancer.

SOURCES: May 15, 2005, press briefing with Ezekiel J. Emanuel, M.D., Ph.D., National Institutes of Health; Christopher K. Daugherty, M.D., associate professor, University of Chicago; Sherri N. Sheinfeld Gorin, Ph.D., associate professor, Columbia University, New York City
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