Why is cancer treatment less aggressive in Canada than US (in this case?
August 8, 2018 11:44 PM Subscribe
I'm in remission from non-Hodgkin's lymphoma. It seems that the standard chemotherapy regimen for my subtype/stage/etc. of NHL in Canada is significantly shorter than it is in the US. Why is this?
For my specific subtype of non-Hodgkin's lymphoma (diffuse large B-cell lymphoma, stage I, no B symptoms or other adverse factors), doctors in the US prescribed six cycles of R-CHOP chemotherapy (of which I've now completed five). I've been looking online at cancer treatment handbooks, and I've found two that prescribe four rounds for my exact case. Both are hospitals in Canada. I've also found one Canadian study that concluded that four rounds were about as effective as six. My doctors, on the other hand, have told me that six rounds are the standard because they've been shown to be substantially more effective than four. Why the difference in standard protocols?
I asked one oncologist about this and he said it had to do with "resources being an issue in Canada" -- is this really the case and would it really result in less effective treatments being prescribed? Why would resources be more of an issue in Canada than the US?
Does this reflect a more general difference in cancer treatment in the two countries -- i.e. is treatment generally more aggressive in the US than Canada (or other countries), or is this an isolated case, or am I overgeneralizing from two data points and there isn't actually a difference?
The reason for the question is that I'm trying to come an informed decision about whether I want to get the sixth and final chemo session. So far I've been doing everything the doctors said, but it's worrying to think that if I was in Canada, they'd be saying something different.
For my specific subtype of non-Hodgkin's lymphoma (diffuse large B-cell lymphoma, stage I, no B symptoms or other adverse factors), doctors in the US prescribed six cycles of R-CHOP chemotherapy (of which I've now completed five). I've been looking online at cancer treatment handbooks, and I've found two that prescribe four rounds for my exact case. Both are hospitals in Canada. I've also found one Canadian study that concluded that four rounds were about as effective as six. My doctors, on the other hand, have told me that six rounds are the standard because they've been shown to be substantially more effective than four. Why the difference in standard protocols?
I asked one oncologist about this and he said it had to do with "resources being an issue in Canada" -- is this really the case and would it really result in less effective treatments being prescribed? Why would resources be more of an issue in Canada than the US?
Does this reflect a more general difference in cancer treatment in the two countries -- i.e. is treatment generally more aggressive in the US than Canada (or other countries), or is this an isolated case, or am I overgeneralizing from two data points and there isn't actually a difference?
The reason for the question is that I'm trying to come an informed decision about whether I want to get the sixth and final chemo session. So far I've been doing everything the doctors said, but it's worrying to think that if I was in Canada, they'd be saying something different.
is treatment generally more aggressive in the US than Canada (or other countries)
Generally yes, but I don't know if this is the first-level cause. The 'aggressiveness' difference even goes down to the preventative screening, with Canadian guidelines generally being less aggressive because Canada places a greater emphasis on harms to the patient from over-screening and over-treating (e.g. for pap smears, potential risks of an abnormal but ultimately OK result can include stress, depression, and sexual dysfunction).
I can't find many studies that directly deals with the 'aggressiveness' of treatment, but "A systematic review of studies comparing health outcomes in Canada and the United States" by Guyatt et al. periodically touches on it (generally with the result that US is more aggressive but mortality etc. isn't any better). It's also been noted that more colon patients chose the most aggressive form of treatment in the US (79%) than Canada (68%).
I've also found one Canadian study that concluded that four rounds were about as effective as six. My doctors, on the other hand, have told me that six rounds are the standard because they've been shown to be substantially more effective than four. Why the difference in standard protocols?
Differences in diffusion of knowledge and weighing of knowledge and interpretation of studies. If new studies say X, not every doctor will be equally aware of them. Even if they're aware of them, doctors may find the results unconvincing because study design is poor (poorly controlled - e.g. people with widely different lymphomas, ages, etc.; low sample size; not a randomized control trial; etc.). Even if the study is well designed and the doctor knows about it, they may trust prior studies more, for reasons both rational (e.g. there are more studies of equal value suggesting the existing course of treatment) and not. (There is a tendency to stick with the status quo until evidence becomes overwhelming, and to try to over-treat rather than risk under-treating.) Even if they trust the study and find it convincing, it might be the wrong treatment plan *for you* for reasons which aren't obvious.
It might be time to sit down with your doc and say: What's the best case scenario *for me* for this sixth treatment? The worst-case? What's the best-case scenario *for me* for stopping at 5? The worst case? and then make a decision based on your personal risk tolerance level.
posted by flibbertigibbet at 4:21 AM on August 9, 2018 [8 favorites]
Generally yes, but I don't know if this is the first-level cause. The 'aggressiveness' difference even goes down to the preventative screening, with Canadian guidelines generally being less aggressive because Canada places a greater emphasis on harms to the patient from over-screening and over-treating (e.g. for pap smears, potential risks of an abnormal but ultimately OK result can include stress, depression, and sexual dysfunction).
I can't find many studies that directly deals with the 'aggressiveness' of treatment, but "A systematic review of studies comparing health outcomes in Canada and the United States" by Guyatt et al. periodically touches on it (generally with the result that US is more aggressive but mortality etc. isn't any better). It's also been noted that more colon patients chose the most aggressive form of treatment in the US (79%) than Canada (68%).
I've also found one Canadian study that concluded that four rounds were about as effective as six. My doctors, on the other hand, have told me that six rounds are the standard because they've been shown to be substantially more effective than four. Why the difference in standard protocols?
Differences in diffusion of knowledge and weighing of knowledge and interpretation of studies. If new studies say X, not every doctor will be equally aware of them. Even if they're aware of them, doctors may find the results unconvincing because study design is poor (poorly controlled - e.g. people with widely different lymphomas, ages, etc.; low sample size; not a randomized control trial; etc.). Even if the study is well designed and the doctor knows about it, they may trust prior studies more, for reasons both rational (e.g. there are more studies of equal value suggesting the existing course of treatment) and not. (There is a tendency to stick with the status quo until evidence becomes overwhelming, and to try to over-treat rather than risk under-treating.) Even if they trust the study and find it convincing, it might be the wrong treatment plan *for you* for reasons which aren't obvious.
It might be time to sit down with your doc and say: What's the best case scenario *for me* for this sixth treatment? The worst-case? What's the best-case scenario *for me* for stopping at 5? The worst case? and then make a decision based on your personal risk tolerance level.
posted by flibbertigibbet at 4:21 AM on August 9, 2018 [8 favorites]
I previously asked a similar question (about France and multiple myeloma). Some of the answers I got might be helpful to you.
posted by FencingGal at 7:09 AM on August 9, 2018 [1 favorite]
posted by FencingGal at 7:09 AM on August 9, 2018 [1 favorite]
When my dad was going through (brain) cancer treatment I got the impression (most of) his doctors would treat him as aggressively as standards and insurance would allow, out of a perverse sort of customer service mentality (and/or a fear that failure to recommend the most aggressive treatment possible would be seen as exposure to malpractice). But the interesting thing to me was that one of his doctors (his [female] medical oncologist) did not do that, and dad mostly chose to listen to the [male] doctors who recommended more aggressive approaches. His medical oncologist was the one person who really addressed the risks and tried to be realistic with him about the complications of treatment and how it would change outcomes for him; his surgeon was relentlessly positive about surgical outcomes.
I think the cultural difference is as much on the patient side as the doctor side. Americans may expect the most aggressive treatment because they're paying for it out of pocket and they demand their money's worth (which drives up costs, but that's the system we have). And I can't say for sure that my dad's choices were chauvinistic, but I also can't say they weren't.
posted by fedward at 7:57 AM on August 9, 2018 [4 favorites]
I think the cultural difference is as much on the patient side as the doctor side. Americans may expect the most aggressive treatment because they're paying for it out of pocket and they demand their money's worth (which drives up costs, but that's the system we have). And I can't say for sure that my dad's choices were chauvinistic, but I also can't say they weren't.
posted by fedward at 7:57 AM on August 9, 2018 [4 favorites]
You might be interested in the work of Vinay Prasad, an oncologist who has examined and critiqued the claims of many cancer researchers and drug makers. Here's his Twitter page.
Not to say he's spoken to your specific question, but speaking very broadly, Canada is somewhat more likely to base treatment recommendations on firmly established research and US practice is more frequently influenced by some combination of drug company pressures, wishful thinking, and the erroneous bias that more treatment is better.
I can't speak to your specific cancer, only in broad terms about cancer treatment.
posted by latkes at 8:40 AM on August 9, 2018 [1 favorite]
Not to say he's spoken to your specific question, but speaking very broadly, Canada is somewhat more likely to base treatment recommendations on firmly established research and US practice is more frequently influenced by some combination of drug company pressures, wishful thinking, and the erroneous bias that more treatment is better.
I can't speak to your specific cancer, only in broad terms about cancer treatment.
posted by latkes at 8:40 AM on August 9, 2018 [1 favorite]
More aggressive treatment isn't always better for the patient. "Limited resources" are only involved here in the sense that the government might not pay for 6 treatments if 4 is just as effective in terms of overall outcome (and sometimes a drug can be more effective in a tumour-shrinking sense without actually being more effective - or even being worse - for lifespan and/or quality of life, which are really what you care about). In Canada there's more of an emphasis on testing whether the treatment is clearly effective so it's worth the resources, whereas in the US as long as you can pay, it seems like you can get all sorts of not super necessary but possibly helpful medical things done. I suppose there are pros and cons of both systems but it is not about the government being too broke to fund an effective treatment.
As to which treatment plan is likely to have the best outcome for you... it's complicated. Different doctors may interpret the data differently, as described above, which is why second opinions are a thing. There are standard treatments, but cancer can be very dramatically different patient-to-patient, and your individual background often affects what's likely to work best for you. Patient factors like age and other health issues can influence how aggressively they want to treat as well. It's a shame that your doctors couldn't explain more clearly why they think 6 is better for you. A different doctor might agree with them or not. You could try asking your other doctors, or asking for a second opinion.
In a much more general sense you may be interested in reading about the Choosing Wisely campaign. I've only interacted directly with the Canadian branch but it's a global initiative to reduce unnecessary tests and treatments (which often have health risks and affect quality of life - it's not just about wasted resources). They thoroughly review the evidence, and are doing excellent work.
posted by randomnity at 12:08 PM on August 9, 2018 [2 favorites]
As to which treatment plan is likely to have the best outcome for you... it's complicated. Different doctors may interpret the data differently, as described above, which is why second opinions are a thing. There are standard treatments, but cancer can be very dramatically different patient-to-patient, and your individual background often affects what's likely to work best for you. Patient factors like age and other health issues can influence how aggressively they want to treat as well. It's a shame that your doctors couldn't explain more clearly why they think 6 is better for you. A different doctor might agree with them or not. You could try asking your other doctors, or asking for a second opinion.
In a much more general sense you may be interested in reading about the Choosing Wisely campaign. I've only interacted directly with the Canadian branch but it's a global initiative to reduce unnecessary tests and treatments (which often have health risks and affect quality of life - it's not just about wasted resources). They thoroughly review the evidence, and are doing excellent work.
posted by randomnity at 12:08 PM on August 9, 2018 [2 favorites]
This might not explain everything but in the U.S. oncologists buy chemo drugs themselves from pharmacies and then charge the patient a 6% or more markup when they administer them. For a $10,000 treatment, this comes to a $600 incentive to do another round of chemo or else prescribe a more expensive alternative when a cheaper one does as well.
Doctors argue over the significance of this obvious conflict of interest, but there is some research to back up the idea that it does influence the use of drugs in some cases.
posted by JackFlash at 1:06 PM on August 9, 2018 [1 favorite]
Doctors argue over the significance of this obvious conflict of interest, but there is some research to back up the idea that it does influence the use of drugs in some cases.
posted by JackFlash at 1:06 PM on August 9, 2018 [1 favorite]
This thread is closed to new comments.
If you want to be evidence-based in your decision, you need to look at the latest studies for your disease state. When I was being treated for cancer, I did similar research and talked with my oncologist about what I was looking at. I have a public health masters degree, though, so I was academically prepared to review and evaluate the quality of the trials. And my onc was sort of charmed by the fact that I took the time to understand why in a constructive, not challenging way. YMMV I also did this at the start of treatment, not at the end.
All that said, why are you considering skipping the last round now? Have you had problems with symptom management? Is cost a concern? Are you experiencing irreversible side effects? I would talk to your onc about your underlying concerns and figure out whether to move forward based on that (people definitely stop chemo early when they have dangerous side effects). In my opinion, just being sick and fucking tired of it is not a great reason to stop.
Finally, the average doc knows basically nothing about the health care systems of other countries, so the doc’s statement about resources in Canada is best regarded as heresay or politics.
posted by jeoc at 4:09 AM on August 9, 2018 [4 favorites]