What added value is there is choosing a Comprehensive Cancer Center (CCC), or an expert dedicated to prostate cancer (in our case, for example) treatments in private practice?
While the US indeed has some of the best cancer care in the world, there are clear disparities in cancer diagnosis and treatments documented in a report last year between the top cancer centers and the community settings (local hospitals and generalists in private practice). [Note that this report was not prostate cancer-specific; it addressed all cancers, but some prostate cancer examples were given.] First, in order to tee-up the heart of the comparison, consider the two opposite ends of the spectrum:
On the one end of the spectrum, some tumors are so non-threatening and their treatment so standard, that it shouldn’t (and doesn’t) matter where you go…your chances are pretty good either way. For common cancers such as prostate, breast, and colon, the surgery can be very well done in non-CCC settings and the survival rates are comparable to those at the elite cancer centers. Five years after the nine most common cancer surgeries, the study reported 62% of the patients treated at the CCC centers were alive, compared to 58% at the community hospitals…a difference, but not a huge difference.
On the other end, against some cancers, even the top medical wizards are helpless. Ted Kennedy’s case of glioblastoma was referenced; he lived 15 months after his diagnosis despite treatment at the Duke University CCC, just slightly over the median survival period.
What about the millions of cancers cases in the middle—those that are neither hopeless nor straightforward (or as straightforward as cancer can be)? Here is where differences in outcomes based on where you are treated were most noteworthy. Fox Chase Cancer Center (in Philadelphia, a CCC facility) provided this data, for example, on the five-year survival of stage-4 prostate cancer patients which highlights the differences: 71% at Fox Chase versus 38% nationwide average.
The quality-of-care differences found in the study were, interestingly, not related to who has the newest, coolest multi-million dollar machine, in which case one could forgive small community hospitals for lagging behind. Instead, it comes down to such basics as experience; to getting the correct diagnosis; to whether doctors address holistic aspects of diet, exercise, and psychological health; to whether doctors routinely test tumors for molecular markers that can guide therapy; to whether multi-disciplinary care is coordinated or haphazard; to how well doctors monitor patients (after surgery, radiation, or chemical treatment) in order to minimize the chance that the cancer will recur. Examples were provided in the report, three of which I will bullet here:
· Prostate cancer patients already know the importance of expert biopsy pathology readings. The physician-in-chief at MD Anderson (CCC site) estimated that patients traveling to Anderson have an incorrect diagnosis from a community pathologist about 5 to 10 percent of the time. Clinically important diagnostic errors can lead to improper or incomplete treatment. From my personal experience, although I had an initial biopsy reading from Bostwick (known expertise in prostate pathology), when I moved from my local urology generalist who diagnosed me to a CCC my slides were re-read for confirmation at the CCC pathology lab.
· Another rule that we prostate patients also already know about surgery is to select experienced surgeons. Outcomes for complex surgeries have significantly disparities between top cancer centers and community hospital settings. For tough surgeries, you want the doctor who’s been around the block, so to speak; surgeons at the top centers have generally sharpened their teeth elsewhere first. Furthermore, length of stay and rate of surgical complications are lower at the top centers versus community settings.
· It was interesting (to me, this was one of the most interesting aspects) how the report characterized a general difference between the approaches of oncologists in the two settings. Doctors in the community setting (generally) report that there is a lot of art in the treatment of cancer, whereas oncologists at top centers say it’s a science. “Art” might sound desirable and even personal—my oncologist isn’t blindly following a recipe in treating me!—but it covers a lot of sins, notably the tendency of some doctors to pick treatments that worked for other patients, even though those results might have been statistical flukes. The “recipes” are well established (see the link to the NCCN Clinican's Guidelines for Prostate Cancer in the original posting) by the National Comprehensive Cancer Network (NCCN).
The third bullet (above) notwithstanding, the top cancer centers were also found to have a much stronger ethic of trying anything and everything when cases turn desperate. The report highlights that this aspect does not show up in five-year survival data, but can make a huge difference to a patient who gets to celebrate one more wedding anniversary or the birth of a grandchild.
After this report was published last year, the National Cancer Institute (NCI) launched a quality improvement program to help raise the bar at the community cancer center programs. Here’s a link outlining the program: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2764567/
The Association of Community Cancer Centers (ACCC) has also responded (following “encouragement” by the federal government, insurance providers, and medical specialty societies) with a training & education program directed at improving adherence to Clinical Practice Guidelines. See here: http://accc-cancer.org/education/education-guidelines.asp
Now, when your friend tells you they have been newly diagnosed with cancer, you can now point out that while the local community hospital might go a great job of making them feel welcomed and well “cared for”, and they will probably have good results, you now understand why they should consider one of the NCI-designated Comprehensive Cancer Centers for the best possible results.
Once again, I should repeat my closing note from the original post in this thread; I’ll simply copy/paste:
Is very good care also found elsewhere [i.e., in community hospital settings or at private generalists]? Absolutely. Will there be people who feel that they had unfavorable experiences at these centers [the CCCs]? Absolutely. But taking the broad view, these centers [the CCCs and the private expert specialists] would absolutely be considered the cream of the crop.