Special Feature
Cookbook Medicine at Its Worst: Or, Choosing the Wrong Recipe and Not Following One
By Thomas J. Smith, MD, FACP
In my referral practice, i see a lot of people for second opinions. As a consequence, I have the opportunity to review many records, and recently have been troubled by less than optimal care. In each of the cases below, the choice of drug treatment and/or subsequent modification seemed to be less than optimal practice.
In my role as chair of the American Society of Clinical Oncology (ASCO) Health Service Research Committee, I was regularly taken to task for advocating "cookbook medicine." From what I see, some of us do terrific jobs of keeping up and providing state-of-the- art compassionate care. I am not so certain about others.
In reviewing the quality of cancer care in the United States for the Institute of Medicine, colleague Bruce Hillner and I found some striking evidence for better outcomes associated with higher volume or specialized care for Hodgkin’s disease, testicular cancer, breast cancer, and some others. This information will be available on the Institute of Medicine Website on April 6.
Please review the cases below, and tell me what you would do. (I have changed some of the details to make identity more difficult.)
• How would you communicate back to the primary oncologist?
• What would be a reasonable approach to improving that oncologist’s practice?
• Do either of these cases breach the standard of care?
Case 1: A 25-year-old man is referred to you for treatment of recurrent Hodgkin’s disease about a year after finishing his first treatment. At diagnosis in 1997, he received six cycles of COPP (cyclophosphamide, vincristine, prednisone, and procarbazine) then radiation. He has a recurrence in the lung/adjacent lymph nodes within the radiation field. Your concerns include:
1. You find, after conferring with the Hodgkin’s disease expert, that the last publication on COPP was in 1975. It was judged to be no better than mechlorethamine, oncovin, procarbazine, and prednisone (MOPP) or CVPP, so never became mainstream practice. Was MOPP or its lesser cousin thefirst choice of treatment for Stage IIA Hodgkin’s disease in 1996?
2. When you calculate the dose of his prior treatment, you find that he only got about 50% of planned doses due to dose capping to whole vials, seemingly arbitrary dose modifications, etc. He never had febrile neutropenia. The dose modifications for COPP are not readily available to cross-check.
3. You also note, after talking to the family, that no mention was made before treatment of the possibility of sperm banking or sterility caused by the drugs.
4. The first oncologist was preparing to treat the lung nodule with "salvage" chemotherapy without a tissue diagnosis.
5. And give Bleomycin to a person who had received mantle radiation without checking pulmonary function tests.
Case 2: A 61-year-old woman is referred to you for recurrent breast cancer in the lung. She had a 7 cm, 5/8 node positive, Grade III, ER- and PR-negative cancer two years prior. She had a mastectomy, then six cycles of CMF. Your concerns include:
1. When you calculate her dose-intensity, you find that due to dose-capping to whole vials, and seemingly arbitrary dose modification, she received only 40-56% of the planned doses. Had the doctor used NSABP guidelines, she would have received 83% of each drug, and would have finished weeks earlier, here is cycle 3, day 1. (See Table.)
2. She was put on tamoxifen even though ER and PR negative. At recurrence, tamoxifen was stopped and megestrol acetate was started, for "weight loss."
3. She also has three first-degree relatives with breast cancer, some as young as age 33, and no one had documented consideration of genetic counseling or plans to ensure that she informed her relatives of increased risk of cancer.
| Table | ||||
| Case 2: Cycle 3 Day 1 | ||||
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over 6 cycles |
over 6 cycles |
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| M |
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| F |
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| __________________________________________ | ||||
How would you communicate with the primary oncologist?
In each case, the family had independently sought a second opinion, and the primary oncologist was not a frequent referrer of patients to your practice. That makes it easy! Don’t send anything back at all! No, that doesn’t seem right.
I don’t know what the etiquette is here, but if I were the first doctor, I would be angry if my patient saw someone else and I did not get a copy of the consultation. So, I would argue to send a full report.
What would be a reasonable approach to improving that oncologist’s practice?
That is, if you agree that COPP is not the best treatment for a 25-year-old man who might reasonably want to preserve fertility and maximize chance of cure, and that dose-modification without good reason compromises CMF efficacy.
The options would be to:
1. Call the oncologist and discuss the case directly (maybe there was some unwritten, undiscussed reason for those choices and modifications).
2. Call your risk management team first to make sure you do not run afoul of any litigation risk.
3. Tell the patient and family that their survival may have been compromised by dose modification and suboptimal regimen choice.
4. Call the state board of medicine and issue an anonymous complaint.
5. Do nothing.
What would be the right approach? What would you do?
Does either of these cases breach the standard of care?
Sorry, but I don’t want to discuss this. But, oncologists have nearly come to blows over a few people per 100 comparing MOPP/ABV to adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD). Should we not care if a regimen with less success is chosen, then modified?
Is cookbook medicine the answer?
I got tired of being skewered for suggesting standardization of what we do, but these appear to be a couple of clear cut cases for cookbook medicine. And following the recipe. Some would say it is a good case for weeding out some of the less-than-optimal practitioners. If someone does not do CMF by the book, how are they at palliative care?
Neither of the above cases are that difficult, at least in terms of describing some optimal therapy. Here is one simple way of maintaining optimal care for a practice:
1. Decide on one "best" treatment for each of the 20 most common oncology situations.
2. Update it each year by comparing it to the NCI’s state-of-the-art treatment programs. They are not meant to be proscriptive or prescriptive, but offer the latest evidence. COPP is not listed.
3. Write down all the standard dose modifications for the 20 regimens chosen, from the original article or research protocol. No one can remember them all; if you improvise, you potentially compromise care.
4. Pick two charts per disease each year for "auditing" and see how the actual practice went. This two- chart audit is behind much of the Institute for Healthcare Improvement simple strategy for making care better.
5. Make your colleagues accountable for following the programs. (Where were the partners of the first Hodgkin disease oncologist when this was happening? She did not practice alone.) Education alone— "Well, we have the right antibiotics for febrile neutropenia 66% of the time. Here is what we did, without any names attached." This works well with no need for punishment.
I would predict that the whole "quality" movement will heat up this year. There is more and more evidence that some practice groups have better outcomes than others, often related simply to higher volume and experience. We should distill what makes for the best outcomes and practice in that way. To do anything less—to give a patient a 5% or 10% less chance of cure by choosing the familiar rather than the optimal—is simply not medically justifiable.
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