Cancer Decisions - Free Newsletter -May 27, 2007

THE NEED TO KNOW

Studies have repeatedly shown that patients with cancer feel they are not given nearly enough information by their physicians. Patients who feel under-informed are more likely to suffer from anxiety and depression, and frequently have measurably reduced well-being.

Most patients want to know as much as possible about their disease, regardless of whether the news is good or bad. In one large study carried out in the UK, for example, less than 2 percent of patients expressed a preference not to be told that they had cancer, and over 90 percent of participants stated a strong desire for full information about all available treatments and how they work, as well as a need to be told about all possible side effects (Jefford 2002).

Historically, the medical profession has shown considerable reluctance to involve patients fully in the decision making process. During the 1960s, for example, over 90 percent of US physicians indicated that they felt a patient with cancer should definitely not be told the nature of his or her disease. Although this secretive and strongly paternalistic attitude has now largely dissipated - more than 97 percent of physicians would now unhesitatingly reveal a diagnosis of cancer - clinicians still often greatly underestimate the amount and type of treatment information that their patients need to be given.

The constraints of today's managed care system certainly do not help. While many doctors would almost certainly like to spend more time with patients to explain things in more depth and answer questions more fully, the constraints imposed by the increasingly prevalent managed care system conspire to make the allocated time per visit ever shorter.

The net result is that patients feel unable to make truly informed decisions. Robbed of the opportunity to discuss their medical needs thoroughly with their physicians, people often turn to the Internet for answers. Certainly, the Internet has unlocked the medical libraries and made vast quantities of formerly unavailable medical literature accessible to everyone. But it has also made available an abundance of unreliable information, often couched in pseudo-scientific language, whose concealed purpose is to sell the unwary a product or service that is essentially worthless. Without the necessary background in the life sciences, it can be extremely hard to discern the fallacies in the sales talk or make sense of journal articles and technical literature.

HERE AT THE MOSS REPORTS

For thirty years I have been studying cancer and its treatment, monitoring emerging research and writing about new approaches to cancer in the fields of both conventional and alternative medicine. The Moss Reports are the distillation of my long involvement with the field of cancer. Each report presents the available treatment options for a particular cancer diagnosis, discussing the rationale behind the treatment and objectively analyzing the expected success rate, drawbacks and alternatives.

If you would like to order a Moss Report for yourself or someone you love, you can do so from our website, www.cancerdecisions.com, or by calling 1-800-980-1234 (814-238-3367 from outside the US).

For people who have already purchased a Moss Report on their specific cancer diagnosis, I offer phone consultations. A phone consultation can be enormously helpful in narrowing down the most promising options and arriving at a coherent treatment strategy.

A recent phone consultation client said:

"I'm the former Editor of Natural Health magazine, and so I have some background in researching health problems. But when I was diagnosed with a high-grade nasopharyngeal cancer in 1999, I was nearly overwhelmed with the range of alternative therapies and supplements and conventional treatments I could undertake. I ordered a Moss Report at that time. It proved extremely helpful in allowing me to pinpoint treatments that would best serve me. The Moss Report was exhaustive; it carefully examined the most promising conventional and alternative treatments available. Dr. Moss candidly presents both positive and negative aspects of each protocol; he has no axe to grind that I could detect.

Now eight years later, needing to make adjustments in my program, I have recently had a telephone consult with Dr. Moss. Once again, his insights have been invaluable. We discussed several protocols that appear to be most suitable for me at this time, and he helped me zero in on a plan of action that gives me confidence.

The first thing that I recommend to any new cancer patient: Order a Moss Report. It will save you time. It will empower you and give you peace of mind. It may save your life." - B.T.

If you would like to schedule a phone consultation please call 1-800-980-1234 (814-238-3367 from outside the US), or send an email to Jacquie@cancerdecisions.com.

We look forward to helping you.

CURRENT TOPICS

Also available at our Web site are our Current Topics reports on important aspects of cancer treatment and prevention. These reports can downloaded directly from our Web site, www.cancerdecisions.com:

On Guard - Gardasil (An in-depth discussion of the anti-cervical cancer vaccine Gardasil)
Do Antioxidants and Chemotherapy Conflict?
Mammography, Biopsy and the Diagnosis of Breast Cancer
Herceptin or Deceptin? (An evaluation of the use of Herceptin in breast cancer)
Avastin: Your Money Or Your Life. (A clear-eyed look at the targeted drug Avastin)
The Politics of Hope: Andrew von Eschenbach and the Decline of the National Cancer Institute
The Mexican Cancer Clinics in the Era of Evidence-Based Medicine

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CANCER DOCTORS ARE PAID TO PRESCRIBE DUBIOUS DRUGS - PART II

(Last week, I began a two-part discussion of the class of drugs called epoetins, or erythropoiesis stimulating agents (ESAs), which are widely used in the treatment of cancer-related anemia. I conclude that discussion, with references, this week.)

Double Dipping

Drug company kickbacks to doctors who prescribe epoetins such as Aranesp, Procrit and Epogen total hundreds of millions of dollars per year and are considered an important source of income for oncologists. "The payments have risen over the last several years," said an article in the New York Times, "as the makers of the drugs, Amgen and Johnson & Johnson, compete for market share and try to expand the overall business."

Illustrating the scope of the problem, just one group of six oncologists in the Pacific Northwest received $2.7 million from Amgen alone for prescribing $9 million worth of its drugs last year (2006). Thus, doctors pocketed about one-third of the gross cost of the drugs in hush-hush rebates from the companies.

But doctors actually get paid two ways for using these drugs. Although Federal law bans drug companies from paying doctors to prescribe medicines given in pill form and purchased by patients from pharmacies, companies are allowed to rebate part of the price that doctors themselves pay for drugs such as the epoetins, which are then dispensed in their offices as part of treatment. Doctors receive their rebates after they buy the drugs directly from the manufacturer. They also receive reimbursement from insurance companies or Medicare for the drugs, often at a markup over the doctors' purchase price. While Medicare in 2003 changed its payment structure, private insurers generally continue to pay more. Needless to say, when such payments are combined with the aforementioned rebates, it adds considerably to oncologists' salaries.

The size of rebates is related to the quantity of drugs that the doctors buy. Rebates increase if doctors also agree to use one company's drugs exclusively. Johnson & Johnson said in a statement that the rebates were not intended to induce doctors to use more medicine, but simply "reflect intense competition" in the market for the drugs. "Amgen is dedicated to patient safety," said David Polk, a spokesman for that company. "We believe our contracts support appropriate anemia management and our product promotion is always strictly within the label." But the Times notes that American cancer patients are about three times as likely as those in Europe to get these drugs. US patients also receive higher doses.

As a result of the rebates from Amgen, six US doctors alone made about $1.8 million in net profit on the drugs they prescribed. Doctors have great flexibility in the amount of any drug they prescribe and in the profits they derive, and so there is little to stop them from using higher doses and thereby garnering higher rebates. The companies in question have generally failed to test whether or not lower doses of the medicine might work as well as these higher doses. In the period 2002-2003, for instance, the average EPO dose per week for an American patient was 17.4 thousand units compared to 10.8 in Canada, 8.0 in Britain, 6.8 in Germany and 5.3 in Japan. In addition, while 32 percent of American patients received doses over 18,000 units per week, only 1 percent of German patients did so.

Dr. Ajay Singh, an associate professor at Harvard Medical School, headed a clinical trial that indicated last year that the drugs might be unsafe in kidney patients at commonly used doses. "The burden of proof is for companies and industry to demonstrate that a drug is safe at a certain level," Singh said. Although epoetins were shown to be unsafe as far back as 1996, their use has continued to soar.

Dr. Ronald A. Paulus of Geisinger Health System of Pennsylvania said the three-hospital chain had lowered its use of epoetins by 40 percent. It did this by monitoring patients closely and by the simple expedient of giving patients supplemental iron when necessary, in order to support the body's ability to make hemoglobin. An iron supplement costs pennies per day. (Nevertheless, cancer patients should NOT self-medicate with iron supplements. Such supplements can be toxic and can actually encourage the growth of cancer in some situations. The decision to supplement with iron should only be made by an experienced medical professional.)

Further concerns were raised in 2003 by clinical trials that were meant to show that raising hemoglobin to high levels would make chemo- or radiation therapy more effective. Instead, the trials showed that epoetin usage was capable of accelerating patients' cancer, and may in some cases have been associated with shorter survival, although a recent study financed by Amgen claimed that Aranesp had no effect on patient survival. At the May 10th meeting of the FDA Advisory panel one of the members asked company representatives, "What data do you have to assure me that this is not Miracle-Gro for cancer?"

Dr. Peter Eisenberg, a Marin County oncologist, said that many doctors had been induced to use more epoetins by the financial incentives the company offered, as well as their belief that these drugs were helpful.

"The deal was so good," he said. "The indication was so clear and the downside was so small that docs just worked it into their practice easily. Now it's much scarier than that," he said. "We could really be doing harm."

The Times' excellent articles on the subject have sparked widespread revulsion and outrage. There are at this writing over 200 reader comments at the Times Web site alone. A few doctors have written to say that they had already changed their prescribing practices before the Times' latest revelations and to assure readers they did not personally profit from the use of the drug. But that does not change the fact that the rebate program continues apace, and is apparently widespread. More typical responses are that it is "scary" and "disgusting" for physicians to profit from a potentially dangerous treatment in this way.

As long as oncologists continue to derive a considerable amount of their income from drug company rebates of this kind, their clinical judgment will be suspect. Cancer patients will have no way to know whether a particular drug is being prescribed because it is the right and proper treatment or because it lines the pockets of the doctor who gives it. Oncologists whose prescribing habits are influenced by potential personal gain are engaging in unprofessional behavior, since they are putting their own financial interests above the well-being of their patients. Furthermore, even those who are not themselves deriving an income from the rebated sale of drugs, but who fail to speak out against the practice, are guilty of enabling their more greedy colleagues.

All in all, it is an intolerable situation and FDA's recent warnings, while welcome, hardly make a dent in the overall problem.

--Ralph W. Moss, Ph.D.

References:

FDA Public Health Advisory: erythropoiesis-stimulating agents (ESAs). March 13, 2007. Available at:
http://www.fda.gov/cder/drug/advisory/RHE2007.htm

Berenson, Alex and Pollack, Andrew. Doctors reap millions for anemia drugs. New York Times, May 9, 2007. Available at:
http://www.nytimes.com/2007/05/09/business/09anemia.html?pagewanted=1

Birnbaum S. CT scanning: too much of a good thing. British Medical Journal 2007; 334(7601): 1006.

Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII - Phase 2 Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation, National Research Council available from the National Academies Press at:
http://www.nap.edu/catalog/11340.html

Jefford M, Tattersall MH. Informing and involving cancer patients in their own care. Lancet Oncology 2002;3(10):629-37.

Pollack, Andrew. F.D.A. panel seeks limits on cancer patient drugs. New York Times, May 11, 2007. Available at:
http://select.nytimes.com/mem/tnt.html?emc=tnt&tntget=2007/05/11/
health/11anemia.html&tntemail0=y

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IMPORTANT DISCLAIMER

The news and other items in this newsletter are intended for informational purposes only. Nothing in this newsletter is intended to be a substitute for professional medical advice.