Doctors seem to differ in making medical recommendation for patient versus for themselves

Patients facing difficult medical decisions often ask physicians for recommendations. However, little is known regarding the ways that physicians' decisions are influenced by the act of making a recommendation. Many medical/treatment decisions are difficult to make since various factors are involved.   Having been a patient myself, I usually just told my own doctor to do what is best for me.    

A study in medical decision making seems to suggest that it is even more complicated than I thought.   In a study, 242 doctors were surveyed and questioned with 1 of 2 clinical scenarios (having colon cancer or suffers from avian influenza).  Both involved 2 treatment alternatives, 1 of which yielded a better chance of surviving a fatal illness but at the cost of potentially experiencing unpleasant adverse effects. The researchers randomized physicians to indicate which treatment they would choose if they were the patient or they were recommending a treatment to a patient.

Among those asked to consider a colon cancer scenario (n = 242), 37.8% chose the treatment with a higher death rate for themselves but only 24.5% recommended this treatment to a hypothetical patient (χ(2)(1) = 4.67, P = .03). Among those receiving an avian influenza scenario (n = 698), 62.9% chose the outcome with the higher death rate for themselves but only 48.5% recommended this for patients (χ(2)(1) = 14.56, P < .001).

The conclusion of the paper was physicians (at least in this study) making a different recommendation for patients and for themselves.  The study researchers commented on how physicians perhaps more careful in making decision for their patients and the need to be be publicly defensible than if they were to make decision for themselves.   The study did not conclude that physicians would be a better doctor for themselves.  I agree with this since I know that I am so biased about myself that I am afraid making diagnosis for my own symptoms.  But if you happen to be in the situation needing medical decision and unable to decide yourself,  you may ask your doctor what your doctor would do if he/she were you.  This may give you a different perspective.

Reference

Ubel PA, Angott AM, Zikmund-Fisher BJ.Physicians recommend different treatments for patients than they would choose for themselves. Arch Intern Med. 2011 Apr 11;171(7):630-4

 

Confirming your cancer diagnosis

As oncologists, we rely on making cancer diagnosis based on your tissue (usually obtained by biopsy or surgery).   For most cases, our pathologists are very reliable in making this cancer diagnosis.   However, there are some cases that your cancer may not be as common and the cancer diagnosis may not be as certain.

We published a paper a while ago that illustrated this situation.   We did 2nd review of the pathology report of 720 patients and found15 diagnosis were different than the original diagnosis (2% discrepancy rate).  After reviewing 15 major discrepancies, six surgeries were cancelled, two surgeries were modified, one adjuvant radiation treatment was added, one chemotherapy treatment was modified, and five adjuvant chemotherapy treatments were cancelled.

Doctors (pathologists included) are human and medicine is not an exact science.  Differing opinion occurs and may impact the patient's care.  Thus, if your oncologist seem a bit uncertain or if you have a rare cancer, you may request a second pathology review.   Most oncologists that I know will automatically do so without even letting you know.  But it does not hurt to ask.

Reference
Santoso JT, Coleman R, Voet R, Bernstein S, Lifshitz S.   Pathology slide review in gynecology oncology.   Obstetrics and Gynecology.  91 (5): 730-734, 1998

 

Bevacizumab for cervical cancer

Sorry, I have not written for a while.   I have been busy getting a few papers published.   It was nice from some of you to send me email to encourage me to keep writing this blog.  So here it is.

Women with recurrent, metastatic, or advanced cervical cancer usually have poor prognosis.   The salvage treatment consists of limited number of chemotherapy.   The chemo that are active in this situations are cisplatin, carboplatin, topotecan and ifosfamide.   A recent study (GOG study number 240) suggests that  chemo combined with angiogenesis inhibitor bevacizumab is more effective than just chemo alone.  In this study,  over 400 women with stage IVB recurrent or persistent cervical squamous cell cancer or adenocarcinoma were randomly assigned to chemotherapy (paclitaxel plus either cisplatin or topotecan) with or without bevacizumab. Although the final study has not been published, the interim analysis showed the addition of bevacizumab to chemotherapy improved overall survival by four months compared to chemotherapy alone (17 versus 13 months).

Unfortunately,  the insurance companies have not approved Bevacizumab for cervical cancer yet for my patients despite my pleas.   I am not so surprised since insurance companies usually wait until final publication as well as NCCN organization’s approval.   UT-West clinic is one of the member institutions for NCCN.  Thus, we will try to push this info to NCCN.

Reference:

NCI Press Release: Bevacizumab significantly improves survival for patients with recurrent and metastatic cervical cancer. http://cancer.gov/newscenter/newsfromnci/2013/GOG240 (Accessed on February 19, 2013