Should you tell patients about beneficial treatments that they cannot have? Yes
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39171.426690.AD (Published 19 April 2007) Cite this as: BMJ 2007;334:826
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Dr Robert Marcus (1) indicates the importance of candour in outlining
the choices available to individuals. However, there is also the effect
on wider issues of public health and the availability of treatment options
from which patients can chose.
Unacceptable radiotherapy waiting times have been highlighted by the
Royal College of Radiologists for over a decade (2). They have now
started to improve but the last audit in September 2005 still showed that
over half our patients wait longer than one month for curative treatment.
What is probably not made clear to patients is the impact that this can
have on their prognosis. A systemic review (3) has shown that for breast
cancer a wait of longer than 8 weeks carries a 60% increase in the risk of
local recurrence over 5 years. For post-operative radiotherapy of head
and neck cancer, a delay of 6 weeks increases the risk of local recurrence
2.6 fold (3).
Worse than this, delay may render patients untreatable. An audit of
waiting times in lung cancer patients showed that 20% progressed so that
they were unsuitable for radical radiotherapy whilst on a waiting list
(4). An up-date in 2007 showed no change (5).
These are significant risks to patients. Our failure to communicate
them or to bring them into the public arena has contributed to the current
lamentable state of our radiotherapy services. The report of the National
Radiotherapy Advisory Group, which is presently with Ministers, proposes a
plan to address these issues.
References
1. Marcus R. Should you tell patients about beneficial treatments
that they cannot have? Yes. BMJ 2007;334:826.
2. Dodwell D, Crellin A. Waiting for radiotherapy. BMJ 2006;332:107
-9
3. Huang J, Barbera L, Brouwers M, Browman G, Mackillop WJ. Does
delay in starting treatment affect the outcomes of radiotherapy? A
systematic review. J Clin Oncol 2003;21:555-63.
4. O’Rourke N, Edwards R. Lung cancer treatment waiting times and
tumour growth. Clin Oncol 2000;12:141-4
5. Muirhead R, O’Rourke N. Waiting times for radical radiotherapy in
NSCLC. Clin Oncol 2007;19: S41.
Competing interests:
I hold a joint lymphoma clinic with Dr.Robert Marcus.
Competing interests: No competing interests
It is ridiculous, you want to hide,
The rights of information and protecting patient’s life.
You want to conceal the truth,
I thought it was what for medicine stood.
NHS cannot afford it, I can bear
but burying my right of information is a scare.
The ethics of UK medicine is at low
but latest treatment, I deserve to know.
Competing interests:
None declared
Competing interests: No competing interests
Someone (age unknown) is going blind because of macular degeneration
(MD)
The treatment is available but at his own expense not at the cost of the
NHS.
This is the story so far.
How many more are there with similar stories?
Is there anyone who is interested in the causes of macular degeneration,
also occurring in the 'aged' other than 'age-related macular
degeneration'(AMD)?
In my limited experience, there are many 'aged' persons who have been
prescribed and are taking regular doses of statins. Post-marketing surveys
proclaim in no uncertain terms that statins can and do cause peripheral
neuropathies, and is it not the fact that retinal neurons are the
peripheral ends of the optic nerves?
It is to be wondered epidemiologically, how many AMD cases are taking a
statin drug.
Furthermore, would it not be prudent to stop the offending drug and await
regeneration of the neurons, if no irreversible damage has occurred? And
what then if the new treatment is carried out at great expense, and the
offending etiological factor has not been recognised and stopped?
Competing interests:
None declared
Competing interests: No competing interests
Beneficial information?
Should we really tell patients about all the latest technological
marvels? It would appear that too many treatments and technologies have
been launched that afterward had to be removed from the market because of
unexpected side-effects or technical failure.
Early adopters may be keen on sharing their absolute and highly
competitive drive to offer their patients the latest and obviously highest
quality care. Apart from potential harm from offering largely experimental
care one but has to look across the Atlantic to understand what the
economic consequences might be. The USA is spending a multiple per
'adequately' insured citizen compared to Canada, and never has a real
health benefit been established. This will be among the main topics of the
upcoming election in the US. I really hope that every 6th US citizen
currently denied access for lack of health insurance recognises this issue
and will find allies among those better off.
Around the world clinicians should take responsibility and sift
evidence regarding clinical effectiveness while aware of societal
priorities. This may entail limiting access to care that based on
efficiency is not part of the local 'NHS' package. No one seems to be
bothered by young families driving around rusty ramshackle cars lacking
ABS, side air bags and what not, where Mercs and Volvos might save lives.
Yet, being denied a PET scan for follow-up of disseminated cancer or MRI
for a sprained knee seems unacceptable.
Priority setting based on needs and affordability is compatible with
most if not all Western European Health care systems. This should be
cherished and not compromised by 'playing' the public. Primum non nocere
also applies here because sooner or later accidents will occur, and harsh
choices will have to be made anyway! Even from a Dutch perspective NICE
appraisals seem like an elegant solution to several of the challenges,
especially if fast tracks could be applied where indicated.
Competing interests:
None declared
Competing interests: No competing interests