Tuesday, May 20, 2008

Senator Kennedy's Diagnosis and Oncology Disease Management

The Disease Management Care Blog is reporting from Boston tonight. The Celts’ and BoSox festooned apparel of the folks sharing the T to the North End suggests its citizens are preoccupied with some very successful basketball and baseball franchises. However, the really big news tonight is Senator Kennedy’s recent diagnosis of a malignant glioma involving the left side of the brain. The local news is going non-stop.

The DMCB knows enough cancer medicine to recall that the prognosis here is very difficult to ascertain. There aren’t many published studies involving persons in Senator Kennedy’s age category, and gliomas are very heterogeneous tumors with varying degrees of malignancy. As the testing and staging continues, the DMCB offers his prayers along with millions of other Americans.

Yet, the Senator Kennedy announcement led the DMCB to think about general oncology disease management. Many cancers are turning out to be non-curable if treatable chronic illnesses. While the physician colleagues in the oncology community may disagree, many patients with cancer may also benefit from organized population-based approaches to care. Standard oncology treatment is often accompanied by prodigious nursing and social service support. Since that is the standard of care, what additional value would a disease management vendor have to offer?

In the opinion of the DMCB, there are four areas of benefit:

Many patients have difficulty knowing everything they need to know about their condition and the treatment options. While physician-oncologists do an excellent job of education, it’s not unusual for patients to be overwhelmed by the usual counseling, and then there are issues of framing and unintentional bias that can sway the patient toward one treatment versus another. Disease management has a long history of helping patients achieve an unbiased level of lay-expertise in their diseases. Cancer is no exception.

While there is a lot of support in an oncology clinic, the DMCB thinks additional emotional support from DM nurses not only will not do any harm but, for many patients, add considerably to patients’ quality of life. That’s especially true when patients are out of the treatment cycle and aren’t returning to the oncology clinic as often.

Let’s face it: oncology drugs are complicated frightfully expensive and, for many patients with recurrent disease, may not appreciably offer much benefit. Helping patients – and sometimes their doctors - choose the right treatment for individual circumstances based on high quality guidelines is not only cost effective, it’s the right thing to do. Given formulary considerations and cost sharing issues, disease management may also have a role to play in helping patients navigate through the insurance benefit. In addition, if treatment is underway, some meds may need to be taken at home. Remote support may help patients be more fully compliant.

And last but not least, many patients need end-of-life support. While hospice is valuable, many patients choose not to have it or don’t qualify. Enter remote support from disease management. As an aside, one Medical Director from an oncology disease management vendor informed the DMCB that a useful measure of quality in this field is the percent of patients still receiving treatment in the weeks prior to death. Too low and you can surmise the physician is not being aggressive enough, while high numbers suggest the physician is being over aggressive with treatment. The Medical Director indicated these data showed high variability. Disease management may have a role to play in reducing that variation by sharing those data with oncologists and encouraging the use of evidence-based treatment protocols.

Senator Kennedy will not suffer for lack of any support. Yet, his interest in health care has helped millions of other just-us-folks Americans also not suffer for lack of care, including disease management. He deserves a lot of credit. The DMCB wishes him well in this latest battle.


Carolyn said...

I think it is difficult to have a "cancer" program - each cancer is really a different condition. As a clinician, it sure sounds daunting to manage all cancers as one program.

Jaan Sidorov said...

carolyn makes a good point. Not all aspects of cancer care for all patients can be 'managed' by a DM vendor. Yet, there are certain commonalities across all patients (need for education, remote support etc) that may make sense, especially for the more common neoplasms, e.g., colon and breast.

Speaking of which, the recent report on the increase in mastectomies that may be linked to the use of MRI imaging tells me usual care could 'use' all the help it can get.