In April, a surgeon in the U.K. was convicted for carrying out hundreds of cancer operations on women who didn't need surgery. Some of the victims had their breasts removed unnecessarily. One of these women told the court she had lost her marriage, home and job as a result of the surgeon's actions.
Sadly, similar things have happened before. Two years ago, a Michigan doctor was sentenced to 45 years in jail, in part for giving patients chemotherapy unnecessarily. Before that, two women in Ontario underwent mastectomies, even though they did not have cancer.
Such stories make headlines, but the vast majority of medical errors fly under the radar, never making the news. A missed CT scan, an incomplete discussion of treatment options or a forgotten follow-up appointment may seem like small mistakes, but each can have a major impact on a cancer patient's health.
Why do errors occur in cancer care? Delivering treatment is very complicated, requiring input from numerous health professionals – doctors, nurses, pharmacists, radiation therapists, secretaries, students, dietitians. Each small decision introduces the potential for error. Cancer treatments have the potential to save lives when delivered properly, but can be dangerous and life-threatening when applied improperly.
Unbeknownst to many patients, the quality of cancer care in Canada can vary substantially between doctors and hospitals. For example, doctors have known for more than a decade that outcomes are generally better if a patient goes to a high-volume centre – a hospital or medical centre where their type of cancer is treated often. In a high-profile study published more than a decade ago, U.S. researchers determined that the chance of dying from pancreatic cancer surgery was 3.7 per cent among patients operated upon by a high-volume surgeon at a high-volume hospital, but it skyrocketed to 16.3 per cent among patients treated by a low-volume surgeon at a low-volume hospital. This relationship is seen for several different types of surgeries, but it is rare for a patient to ask about their surgeon's level of experience.
If you or someone in your family is faced with a cancer diagnosis, here are some essential questions to ask your doctor to help ensure you are receiving high-quality care:
What is the goal of my cancer treatment?
A curative treatment seeks to get rid of a cancer completely, whereas a palliative treatment is meant to slow down the cancer or improve symptoms, but not cure.
Understanding this distinction is crucial. Patients are less likely to choose aggressive treatments when goals are palliative and can better plan for the future when they are aware of the goals. However, many doctors do not effectively inform patients of their treatment goals. In a 2012 U.S. survey of patients who were receiving chemotherapy for incurable lung or colon cancer, 74 per cent mistakenly believed their chemotherapy was intended to cure. An understanding of your treatment goals will help you make more informed decisions.
Can you explain my cancer's stage, using the reports from my scans and biopsy?
A cancer's "stage" describes its size and where it has spread in the body. The type of treatment a patient receives almost always depends on the cancer's stage: The treatment for a Stage 1 lung cancer is inappropriate for a Stage 4 lung cancer and vice versa. Doctors typically rely on scans to determine the stage and treatment, but often, these scans show uncertainties such as a spot that will need to be looked at again in a few months. Reviewing these reports with your doctor in detail can help ensure that nothing is missed when it comes time to decide upon the best treatment.
What are all the guideline-recommended treatment options for a cancer like mine?
It's difficult for doctors to keep up with all the latest research, so groups of experts create treatment guidelines that doctors can consult. Guidelines tell doctors the options available to treat each cancer, depending on the stage. For example, men with prostate cancer often have several options: surgery, internal radiation, external radiation or close observation. In some parts of Canada, large numbers of men receive treatment with radiation or surgery, with risks of sexual and urinary side effects. In other parts of Canada, the vast majority of men receive close observation. This suggests that many men are not being provided with all the options.
Can you discuss my case at a multidisciplinary tumour board (MDT) meeting?
An MDT meeting is like a team huddle. Cancer doctors get together to review patient cases – often taking a second look at all the scans – and share opinions about treatment. MDT discussions lead to a change in diagnosis or treatment recommendations about 10 per cent to 20 per cent of the time and can be helpful when there is uncertainty about the best treatment.
Are you considered a high-volume provider for my type of cancer?
For many cancers, outcomes are better at high-volume centres, where doctors treat a specific type of cancer frequently. Not only is this important for surgery, as in the aforementioned study of pancreatic cancer, but also for patients getting radiation. A U.S. study published in 2016 indicated that patients receiving chemotherapy and radiation for Stage 3 lung cancer were 18-per-cent more likely to be alive five years after treatment if they were treated at a high-volume centre. Going to a high-volume centre may require travel and, in such cases, the potential benefits need to be weighed against the downside of leaving home.
Dr. David Palma is the author of Taking Charge of Cancer: What You Need to Know to Get the Best Treatment. He is a radiation oncologist at the London Health Sciences Centre and a clinician-scientist with the Ontario Institute for Cancer Research. He also runs the patient website http://www.qualitycancertreatment.com/