Survey Research at the Clinical Frontlines
In August and November 2011, we wrote here about the increase in oncology drug shortages and the implications for oncology patient care. We’d been moved by alarming media reports, including a New York Times Op-ed by Ezekiel J. Emanuel, MD, PhD, to poll oncologists about their personal experiences in the January 2012 wave of our ongoing survey initiative, “Oncologists Look At Oncology".
Nearly all of the 204 oncologists (95%) who participated in our 2012 survey had seen patients in the prior year (2011) who were unable to receive timely treatment due to drug shortages, with half (49%) encountering this problem on at least a monthly basis throughout the year. A full 85% said they’d had patients who were unable to receive the best therapy at all because of drug shortages. Those data were taken to Capitol Hill by the Community Oncology Alliance as part of a broader conversation that involved Congress and FDA. Some constructive solutions were proposed by health advocates and policy-makers while essentially nothing happened. We have become a society that is extraordinarily patient with the unacceptable.
Cue 2013, and another round of surveys.
This past week, the American Society of Clinical Oncology held its annual meeting in Chicago. At that meeting, Dr. Emanuel and Dr. Keerthi Gogineni reported the results of a new survey of oncologists which they and their colleagues at the University of Pennsylvania conducted in Fall/Winter of 2012-13. Sadly, they continued to find that 92% of oncologists say that their patients’ treatment has been affected by shortages and 83% have been unable at times to prescribe standard chemotherapy.
The Deplorable ‘New Normal’ Requires New Guidelines
Oncologists feel that they lack formal guidance about how to make allocation decisions and, therefore, that they must improvise their responses when drugs are unavailable. Oncologists have substituted scarce generic medications such as leucovorin with more expensive branded options, but the implications of swapping drugs involve far more than reduced cost-effectiveness. They can lead to reduced efficacy and increased morbidity.
In an interview with CBS Radio, Dr. Gogineni commented that, “These are substitutions for which we sometimes don’t have data about how that affects the outcome for a patient.” She went on to suggest that guidelines are needed to inform and standardize the decisions oncologists make in times of scarcity.
And indeed, a disheartening number of oncologists polled in our 2012 survey were already convinced that patient outcomes have already been affected by shortages. Almost half (48%) believed they had had patients whose tumors had recurred because of drug shortages and 40% had at least one patient whom they believe had died sooner. Opinion surveys of oncologists cannot and should not carry the weight of well-designed empirical assessment of patient outcomes, but oncologists are the first to see that these shortages have consequences, and we ignore the early warnings at patients’ peril.
Safeguarding Legacy Drugs While We Still Need Them
Oncologists have always prided themselves on practicing evidence-based medicine long before “evidence-based” had become a medical mantra. We should be indignant that patients are now forced to be treated with something other than the evidence-based standard of care simply because we have not found a way to ensure the availability of the best medicines. And we should despair to think that things have gone so far that there is now a call for new guidelines to compensate for loss of old but important drugs. Our emphasis on medical discovery should remain absolute and unqualified. But there is grim irony in the implication that forward progress toward newer, more expensive therapies continues to have as an unintended consequence the loss of cheaper therapies we already know to be critically important.