The Slippery Slope

Some fifteen or so years ago Cancer Clinics in Canada did not prescribe Tamoxifen to patients who were found to have stage one breast cancer. As a family doctor I would receive a copy of a letter that had been sent to the patient from the Cancer Clinic. In short it would say something to the effect that the patient was lucky to have the earliest stage of breast cancer and no other treatment was required. I had read research that indicated Tamoxifen significantly lowered the recurrence rate of stage one breast cancer so I made an appointment with one of the head oncologists at the Calgary Cancer Clinic. To my surprise I was told that this information had been known for eight years but there was not yet evidence that it lowered the DEATH rate. After some discussion and subsequent phone calls to other clinics across Canada I found out that the problem was a budgetary one, and until real survival rate improvements could be shown, the drug would not be covered. However, shortly after significant national publicity, Tamoxifen was prescribed for most women with stage one breast cancer.
The issue though is the accuracy of the information given to the patient and the family physician at the time. Should the letter not have stated that Tamoxifen lowered the recurrence rate? To most patients, recurrence of cancer is equated with eventually dying of the cancer. Should not the patient have had the option of paying for the drug themselves? The confidential answer I got was that politically this would be unwise since it would seem the system was being negligent in providing necessary care.(accurate!).
The experience with Tamoxifen must raise questions about access to drugs and treatments in today’s cost effective orientated system. How many drugs and treatments (not just for cancer) are being withheld because of cost or haven’t been proved to save lives,( but have been proven to prolong life or improve the quality of life)? When discussing treatments with patients are physicians presenting only that information to the patient that is cost effective?
Recently, I obtained information about a treatment program for treating cancerous liver tumors. The control group’s life expectancy was seven months, the treated groups life expectancy ranged from 24 to 48 months. Is this program available in Canada, or will it ever be available since all patients in the study eventually died? (Keep in mind we all eventually die). The side effects of the treatment program were described as mild and the quality of life described as good in the extended months. Will patients who qualify for this treatment be told of its existence since it would be costly and out of country? We say that a patient should have full disclosure of treatment options but the question is: “Have the approved treatment options been predetermined by a mentality of cost effectiveness?” Have we learned nothing from the hepatitis C disaster? When physicians become business men who do we turn to for medical advice?
In the Calgary region when a patient enters a long term care facility a CODE status is established with the patient and his/her family. This basically is a determination of the degree of medical intervention the elder wishes should negative medical events occur: e.g. heart attack, heart stoppage, pneumonia,---- and what action the elder wishes the nursing home to take e.g. resuscitate, transfer to hospital, treat on site, etc.
To make a reasonable decision full disclosure of potential benefit and potential harm should take place. If the information given is pro intervention, medical treatments may ensue that the patient may not wish, but, if the information has a “cost effective” priority, the patient may not receive treatments that could be beneficial. This could be a life or death decision!
I have been assured many times by leaders in “cost effective medicine” that a price is not put on a human life, but the research will actually quote how many people need to be treated to prevent one death. Why is a treatment not offered when it will extend life but not necessarily save life? Is there no deemed value to an additional six months of life? By the very nature of our monopolistic universal (one size fits all) system the care providers will present information that will shape the decisions made. In a system that is “cost effective” the decisions on the part of the patient (unknowingly) will tend to be cost effective. Dying quickly is cost effective unless there is still much taxation potential. Prolonging life in the terminally ill and the frail elderly likely has little taxation benefit.
Shouldn’t we all be just a little bit more paranoid about our Universal (one size fits all) monopolistic health care system? In ancient times sacrifices were made to the gods. What sacrifices are we making to the Canadian Medicare god?