Archive for the ‘Cancer’ Category

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A dangerous trick of the mind…

May 22, 2007

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The Medical Protection Society Casebook publication has a fascinating article today on Involuntary Automaticity (IA). This is what happens when the involuntary side of the brain takes over something that you do in the same way repeatedly, like driving. It may also account for why some medical errors are made, when we have fixed protocols for everything and IA takes over from the conscious checking mechanism. It’s also more likely to happen (to both parties) when 2 people are following a protocol which requires them both to check it, as they both involuntarily assume that the other person has done whatever it is they are supposed to check. So in a rather bizarre twist it means that changing a medical protocol from something which an individual has to make a conscious effort to think about and do into one which has pathways and guidelines which tell us what to do, with built in checks, may actually lead to more errors being made. This, rather worryingly is what pilots do on landing and take off.

It is also a particular issue in oncology where the driver is for ever more tightly controlled policies and guidelines, and is thought to have been a factor in the recent tragic case in Glasgow of a 16 year old girl who received a huge overdose of radiotherapy for a brain tumour last year. I can certainly think of occasions when I could have sworn I had checked something, but when I have double checked it it is clear that I can not have done.

Maybe it’s time to get rid of all the protocols and guidelines and go back to properly trained doctors taking responsibility for what they do, rather than expecting half-trained sub-consultants to get by through rigid adherence to defined procedures…

UPDATE

By a bizarre twist of fate at our clinical governance meeting we have just discussed a case where radiotherapy was given to the wrong area because a single mistake was made in annotation at the beginning of a patients journey.Despite (or because of) rigid adherence to protocol and an inbuilt check system, the mistake was not detected and ultimately led to this error, which thankfully should have no long-term sequelae. In retrospect this is quite a clear case of IA.  I was able to sound surprisingly knowledgeable about systems theory.  The Casebook article suggests the following remedies for IA:

  • Teaching doctors about systems theory
  • Adapting protocols to generate tactile and oral responses
  • Creating effective relationships between managers and clinicians
  • Using independent checkers
  • Developing different checklists to keep clinicians alert
  • Involving patients in their consultations more effectively
  • Minimising stress levels
  • Reducing distractions
  • Although I believe there is no substitute for good training and individual (rather than collective) responsibility, I think most of these sound very sensible, and especially the last three.  The patient in question knew the correct information which would have prevented him from getting the wrong treatment.  If only he had been asked…

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    A Tale of three drugs

    May 11, 2007

    Non-medics may care not to read this!

    Dr Crippen has THIS post today about the lack of availability of Tarceva (erlotinib), a drug about which he has strong views and has previously posted. I think it may be helpful to consider the case of this drug in a little more detail. Tarceva is a drug which is licensed for the treatment of lung cancer after previous chemotherapy. It is no available on the NHS as it is deemed by NICE not to be cost-effective (though interestingly it is cost-effective in scotland-work that one out if you can!)

    There are 2 other drugs licensed in this situation, namely docetaxel and pemetrexed. Only docetaxel is available in the NHS. The following are 3 graphs showing the survival figures for 1) tarceva vs placebo, 2) docetaxel vs supportive care and 3) docetaxel vs pemetrexed

    1)

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    2)

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    3)

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    They show (to me, anyway) that both docetaxel and tarceva give a survival advantage over supportive care alone, amounting to an approximately 10% absolute survival advantage at 1 year. The third graph shows that pemetrexed is as effective as docetaxel.

    The costs of these drugs (approximately) are as follows:

    Tarceva £1,800 per month (average course will be around 3 months, may go up to 18 months)

    Docetaxel £6600 per course

    Pemetrexed £8000 per course

    These drugs have different side effects, different risks, one may be more suitable for one patient than another. I believe they all have a role, and in the private sector I am able to discuss with patients the pros and cons of each and come to a decision as to which is better for an individual patient. Why am I not allowed to do the same in the NHS, where the choice is docetaxel or nothing? Just because it is the cheapest does not make it the best choice. Indeed for a patient who is likely to have side effects from docetaxel, tarceva may be more cost-effective. The only people who will be on the treatment fo more than 6 months will be those who are benefiting, and in those patients the drug is cost-effective. The people in the best position to make these decisions are the oncologist and the patient, NOT the DoH. If they had their way, oncology could be practised by automatons.

    Now, that said there has to be rationing in the NHS. There will be drugs and treatments that we cannot afford. I feel, however that if these treatments are available in every other developed country but not the UK, then we have set the cost limit too low, and this is reflected in the fact that our cancer outcomes are amongst the worst in the developed world. It might be that we decide that this is acceptable and we will not devote resources to treating cancer as it is not cost-effective. If so, I will look for a new job.

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    Its true…

    May 10, 2007

    Britain is one of the worst places in the developed world to be if you get cancer, researchers from Sweden’s Kaolinska Institute have shown HERE . But bizarrely one of the leading nations in the world in research against cancer. I am afraid that this will come as no surprise to those of us who treat Cancer for a living.

    However I was interested to hear Karol Sikora, a well known UK oncologist on radio 4 this morning. He says he wants rationing by NICE to be explicit and timely so that the NHS can provide a “core service”, with the implication that people would have to pay for anything over and above the core service. This is not, of course, what Patsy and the DoH want us to believe. You can hear the interview HERE

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    But speaking as I was previously of perverse incentives and conflict of interest, I wondered whether Dr Sikora might have mentioned that he is the leading light behind CancerpartnersUK, a private venture providing oncology services to NHS and private patients, and centres where people will be offered a basic “NHS” package with the opportunity to pay extra (to Dr Sikora’s dispensary) for additional drugs like erlotinib or bevacizumab which are not available on the NHS. So, to look at it cynically, he has an incentive for the basic NHS package to be as basic as possible to encourage his own business.

    Now I think this is a model which may well work and may have benefits, but I think Dr Sikora would be well advised to declare his interest in this organisation, which is more significant than his NHS commitment, which I understand to be minimal.

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    It’s a lie…

    May 10, 2007

    THIS can’t be true. If it is we have to keep it very quiet. I’m certainly not telling Lola!

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    Tangled Webs

    May 5, 2007

    If you think this is just political, stick with it till the end, you may be surprised.

    Reading THIS in the Daily Mirror:

    DAVID Cameron tried to put a brave face on Tory election results yesterday as his hopes of a landslide failed to materialise.

    and THIS in the Soaraway Sun:

    DAVID Cameron turned the map blue last night as he showed the Tories are finally back in business. The Conservative leader was celebrating after winning a whopping 875 council seats in the town hall elections.

    did make me wonder if the political journalists had been reporting on the same election, though I think the map below probably tells the story (look away if blue isn’t your favourite colour)

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    And initially I got quite cross, railing internally and occasionally vocally at the Mirror, Guardian, BBC etc.

    But consider the following statements:

    “I’m afraid you have lung cancer. The prognosis is very bad-most people will live less than a year. The best treaments we have is chemotherapy but that will only add about 8 weeks to your survival time on average (the chemo is a 12 week course) and there is a significant risk of side effects”,

    and

    “I’m afraid you have lung cancer. Although some people have bad outcomes, many people now live for 2-3 years after the diagnosis. I would suggest you have some drug treatment (chemotherapy). We know that the majority of people will see improvements in their quality of life and symptoms, and a significant minority (probably 30%) will also get a major response to chemotherapy and will live longer as a result”

    I use both these sentences (or at least some variation on them-I probably wouldn’t use the first one as it stands) quite often. I use the first when my assessment is that a given patient is not likely to benefit from treatment-for example if they have other major illesses which increase the risk of side effects from treatment. I use the second when I think that people are likely to benefit. Both are true. Both rely on the same data, but it will not surprise you to hear that recipients of statement 1 rarely ask for chemotherapy whereas recipients of statement 2 rarely decline treatment

    So now who’s the spin doctor?

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    Playing GoD

    April 26, 2007

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    Today the HFEA issued a decision on pregestational diagnostics or PGD. The press release can be read HERE. In short it says that we should look at the possibility of allowing families with high risk of having children with inherited cancer genes to screen embros to select out those with the abnormal gene. This seems like a very humane and sensible thing to do, and having seen young men and women die of these cancers, and women forced to have bilateral mastectomies and oophorectomies (surgical removal of the breasts and ovaries) at a young age because of their high risk of cancer, I am immediately sympathetic to this decision.

    But…on the other hand I wonder. I am inherently and rather uncharacteristically Luddite about this sort of technology. What sort of a world will we move into when we can select particular characteristics for our children? Is it right to be creating embryos and then discarding them? Who will have the rights to these discarded embryos? How do we make a moral difference between selecting for cancer or for cystic fibrosis, or for blondeness, blue eyes or being gay, even (if such a gene is ever found). We are entering a new world with different ethics and values, and with less of the great mystery and magic which makes me glad to be alive.

    What joy will there be in the birth of a child we have designed? Will it be the same as the new car we ordered from the catalogue, or the flat we buy off plan? How disappointed will we be when they don’t turn out to be perfect (because they won’t)? Playing with our genetic makeup gives us the illusion of power, but it is just that, an illusion. In the end we will all die, and some will die younger than others. I think perhaps I would prefer the unknown.

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    But I think if I was a carrier of the BRCA1 or BRCA2 genes, which give a very high lifetime risk of breast cancer (36-85%) and ovarian cancer (16-60%), or the HNPCC gene, which gives an 80% risk of colon cancer, I would probably have the test, and I would probably take up the offer of PGD. Does that make me a hypocrite or a pragmatist?

    Both, I suspect

    But on a health economic assessment I’m sure this procedure offers value for money, as the cost of PGD will be much less than the cost of treating the subsequent cancers. So on purely economic grounds I can support it unreservedly and leave the moralising to others. So there we are, problem solved. Easy, this ethics business.

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    Topping up again

    April 25, 2007

    In an interesting new take on the approach to top-up payments in the NHS, reported in the Times HERE, A leading insurer has started a policy in which patients will be able to pay an amount equal to their age per annum, for which they will bee guaranteed access to £50,000 worth of cancer drugs if they are licensed but not available on the NHS. An interesting proposition? Well yes, but lets look at the exclusions. If you have cancer-not eligible. If you are over 65-ditto If any relative has developed cancer under 65 ditto. So in fact I think this is a bit of a loss leader to try and get people to take up their more inclusive policies, when they realise how little advanced cancer treatment is available on the NHS. But of course they have a real incentive to promote the top-up approach as it will potentially save them huge amounts of money compared to wholly private treatment

    Including my fees!

    Lola-break out the Lafite 61. I think I may need a drink. Speaking of top-ups lets go for a spin. I may have to sell the Bentley

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