Where did cancer education for non-oncologists go?

*Note: This post is based on my (limited) experience as a trainee in medical school and residency at one institution (University of Toronto). If you have had a different experience please share in the comments or on Twitter

On the weekend I wrote “Diagnosing cancer is hard” and said I would later write about what can be changed on the physicians’ side to improve diagnostic skills, and well…I lied. I don’t have any great insights into that. What I would like to discuss is the lack of general oncology teaching for non-oncologists.

Cancer is responsible for 30% of all deaths in Canada; two in five Canadians will develop cancer in their lifetime and one in four will die of it (Canadian Cancer society). Survival rates are increasing, and patients even with advanced or metastatic disease are living longer due to new treatments, turning cancer in many patients into more of a chronic disease. Yet many doctors on the front lines (family physicians, internists, other specialists) are much less comfortable treating the issues that surround active cancer (or side effects from treatment) than they should be. And I believe that it all stems from a lack of education, starting in medical school, and continuing throughout residency.

The first two years of my medical school were lectures on anatomy, physiology and organ systems. There are two months in first year on cardiac physiology, and another two months on clinical cardiology in second year. Comparatively, there is nothing on cancer in first year, and a total of 5-10 hours in second year (an hour for each of the most common types of cancer). There is a grand total of one hour of radiation oncology across all four years, yet 50% of the 200,000 people diagnosed with cancer each year in Canada will get radiation at some point as part of their treatment. Radiation treatment is a giant black box to pretty much all non-oncologists. In clerkship, there is zero mandatory clinical oncology time. Western University used to have two weeks of mandatory clinical oncology, but they made it elective a few years ago. I am not aware of any university in Canada that has any mandatory clinical oncology rotations in clerkship.

Family medicine residency has no clinical oncology time and almost no formal teaching on it. Internal medicine has a single four week medical oncology rotation across the first three years of residency, and one half day of formal teaching per year on cancer. Yet family doctors and internists see and treat cancer patients (cured, on treatment, or coping with metastatic disease) all the time. I believe this needs to change, and that patients will be better off if all doctors are more comfortable and knowledgeable about oncology. Palliative care doctors should not be the only non-oncologists with a significant clinical oncology education. Generalists (internists, GPs) are well equipped to treat diabetes, hypertension and other prevalent diseases because they are trained for it; what about cancer care?

I will use one example to illustrate my point, but I want to remind my readers that I know next to nothing about the economic and political aspects related to the following example. Many breast cancer patients are now on hormonal therapy (such as tamoxifen) for 10 years after diagnosis. The chances of a new complication from these pills, or of a recurrence of their cancer, is increasingly remote after 5 years of follow up. Yet these patients are seen in an oncology clinic every year in order to go over their mammography report, get a prescription refill, be monitored for side effects, and undergo a clinical breast exam. These patients often have to travel a significant distance (several hours in some cases), pay $25 in parking, and have the added anxiety of knowing they have to come back to a cancer centre every year. It is not my goal to criticize medical oncologists in any way with this example. I would simply assert that years five through 10, family doctors could take over this responsibility with the option of re-referring to the cancer centre should issues arise. Patients could stay closer to home, save money on parking and potentially have their anxiety reduced if they saw their GP instead. It could be part of their annual physical exam, saving the patient an additional appointment. Yet the infrastructure is not in place for this yet, and I suspect many family doctors need more education in order to be comfortable prescribing and monitoring hormonal therapy for breast cancer. The same type of argument could be made for long term PSA follow up for men cured of their prostate cancer, and likely many other situations that I cannot think of off the top of my head.

In cases like this, patients would be equally or better served if some of the clinical work could be offloaded from an already overloaded oncology sector to a primary care setting. From a GP’s office to general inpatient hospital wards, cancer care could improve if non-oncologists had significantly more education in oncology. To do this, oncology education needs to truly start at the undergraduate medical education level and be supported throughout residency for all doctors in training.


Diagnosing cancer is hard

During my time on service working in oncology clinics, I see probably one patient or more a month who is angry or upset that their cancer diagnosis took between months and years from the start of symptoms to the time of diagnosis. In a future post I will write about my thoughts on what can be done on the physician side of this issue; today I want to write about what patients should understand in order to reduce their anger and frustration.

Basically, diagnosing cancer is extremely hard to do. As with the rest of diagnostic medicine, it is more of an art than a science. Primary care physicians see patient after patient with a wide range of complaints, the vast majority which turn out to be from benign causes. If all of these complaints led to an x-ray/ultrasound/CT scan, the health care system would be stretched way too thin, there would be significant harm from chasing down incidental findings from these scans, and there is no guarantee that these tests would pick up an early stage, small cancer in the first place. I’m not sure oncologists understand just how hard it can be to pick the appropriate patients in whom to arrange a “cancer workup” since almost all patients we see come with a biopsy proven tissue diagnosis of cancer, and we never see the patients with similar symptoms who fortunately don’t have cancer.

The public has the perception, via the media and public campaigns, that the medical community is making great strides in the area of cancer research. And while this is true in terms of treatments (better focussed radiation, new pills that target cancer cells specifically), very little has changed in terms of being able to diagnose cancer earlier. While the public is also well aware of the few successful screening programs (including Pap smears, mammography and fecal occult blood for colon cancer), I get asked regularly “Isn’t there a way to screen for cancer X” (where X is thyroid, lung, ovarian, etc). And unfortunately, despite a lot of effort, most cancers do not have any effective screening tests. There are some blood tests that are useful to monitor after a patient has a cancer diagnosis, but none have been shown to effectively screen patients in order to diagnose cancer (outside of PSA for prostate cancer, which is a topic for another day).

I hope I am not coming off sounding paternalistic by telling patients they shouldn’t be upset or angry when it takes a long time to be diagnosed with a potentially life threatening disease. Those are natural feelings in such circumstances. I just want patients to understand that their primary care doctors and other physicians they have seen along the way are not incompetent and are doing their best to act in patients’ best interests. What’s important is to try to move beyond whatever happened in the past and focus on getting through the necessary treatments to achieve the best possible outcome.

Bilateral mastectomy – overtreatment?

This week’s radiation oncology (#radonc) twitter journal club featured the recent paper (http://www.ncbi.nlm.nih.gov/pubmed/25182099) that, in part, showed an increase in the rate of bilateral mastectomy (BLM) for early stage breast cancer from 2% in 1998 to 12.3% in 2011. Broken down by age group, over 35% of women under 40 years old, 20% aged 40-49, and 10% of women 50-64 are now getting bilateral mastectomy when a unilateral lumpectomy and radiation is a viable alternative.

I was quite taken aback when I heard those numbers, especially once learning that the same study showed absolutely no survival difference between BLM and lumpectomy. Is this overtreatment gone overboard? It is not shocking to learn that those most likely to get BLM were white, affluent, and had private insurance. And while pursuing BLM is a sensitive topic particularly when genetic mutations and strong family histories are involved, the medical community needs to take a step back to consider the current state of affairs.

Some of the patients getting now getting BLM (12% of *all* early stage breast cancers!) do so because they are demanding it of their surgical oncologists in order to ease their anxiety regarding a potential second breast cancer down the road. And surgeons are increasingly agreeing in order to “satisfy” their patients, creating a “new normal” where overtreatment with BLM is acceptable. Since when is major surgery an acceptable answer to dealing with patients’ anxiety? If a major celebrity were to get thyroid cancer, and the public were to learn that the prevalence of occult thyroid cancer is 5-30% from autopsy studies (http://www.ncbi.nlm.nih.gov/pubmed/23517343), would prophylactic thyroidectomies become an accepted practice?

We also now know that the most highly “satisfied” patients cost more to the healthcare system and are more likely to die compared to less “satisfied” patients (http://www.ncbi.nlm.nih.gov/pubmed/22331982). I have written about this (http://www.cmaj.ca/content/early/2013/08/12/cmaj.130366.full.pdf+html) before, but physicians need to be very careful in separating what patients want from what’s best for patients, because these two concepts can sometimes be at odds with each other. This is reflected in the fact that most patients are highly satisfied with their choice of BLM after their surgery despite having a worse body image, sexual function, and substantially more repeat operations and major complications (see Discussion in article linked to in the first paragraph).

I am not arguing that BLM is inappropriate for all women diagnosed with breast cancer. But the high rate and exponential growth in the rate of BLM over time causes me great concern. Currently the most high profile debate in breast cancer is regarding the value of screening mammography; however, I think more attention needs to be paid to the overtreatment of early stage disease.