Just over a decade ago my father-in-law discovered he had melanoma that had spread to his brain. He was told that his cancer was inoperable and there was really nothing that could be done. He went on hospice care and died within a few short months. About one year later former president Jimmy Carter too was diagnosed with melanoma that had spread to his brain. The former president and my father-in-law were of similar age, and both lived in Georgia. Yet, the cancer care they received could not have been more different. The former president had access to the best doctors, who undoubtedly worked as a team. They were motivated and could make time to discuss the latest medical breakthroughs with colleagues around the country. Former president Carter’s cancer care was immunotherapy, something not yet common at the time.
“For the public, Carter put immunotherapy on the map, period,” Drew Pardoll, director of the Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, told the Washington Post. “Patients started asking for it.” It was called “the Jimmy Carter effect.”
“The particular kind of immunotherapy that President Carter and many other people receive is called checkpoint blockade, which is essentially a treatment that cuts off molecular breaks that usually keep our immune system under control,” he explains. “And the idea is that by cutting off these molecular breaks, we let the immune system run at a higher level than it otherwise could, and therefore overcome some of the ways in which cancer can cloak itself from the immune system.”
Hindsight is 20/20 as they say but I do not recall my father-in-law being offered immunotherapy by his Medicare doctor. Was it not available yet? Or did his doctor not know about it?
The Wall Street Journal reports that cancer care is increasingly being tailored to individual patient’s genetic makeup and many local doctors cannot keep up.
Cancer care is getting more complicated, thanks to a better understanding of cancer’s molecular underpinnings. Doctors now think of cancer as more than 100 distinct diseases, with cancers including lung, breast and bladder broken into subtypes.
That complexity is contributing to a divide in how patients fare depending on where they go.
Large cancer centers have both the resources and the size to allow resident oncologists to specialize in specific cancers and cancer subtypes. They often have access to experimental drugs that are not yet approved by the FDA. Why don’t all patients go to big cancer centers, like Houston’s MD Anderson or Sloan Kettering in the Northeast? It mostly stems from human nature. Hospital care is local. Most people don’t want to travel too far for treatment, especially if their treatment goes on for months.
But most people get treated locally to be near home and jobs. Local oncologists, faced with a range of cancers, can’t stay up-to-date on everything. The National Comprehensive Cancer Network updated its nearly 90 guidelines across cancer types more than 200 times in the past year.
“We have to be a jack of all trades,” said Dr. Stephen Divers, an oncologist in Hot Springs, Ark., and chief medical officer at the American Oncology Network, a group of community practices.
As cancer therapies advance the body of knowledge has become far too large for any one oncologist to master. Increasingly oncologists must specialize in small segments of one cancer to keep up. When they don’t mistakes in diagnosis can occur.
A third of 120 patients who sought a second opinion at Memorial Sloan Kettering Cancer Center in New York had their treatment changed, a 2023 review found. MD Anderson Cancer Center in Houston said about one in five of its new patients are rediagnosed or restaged. Patients at academic centers have better outcomes for cancers including lung and multiple myeloma, studies show.
Independent or small group practice oncologists are going away. Older oncologists are retiring while many younger ones are joining larger hospital affiliated practices. The demise of small practices is often blamed on hospitals buying up lucrative oncology practices to capture referrals, but another major reason is the sheer complexity of medical advancement in oncology.
You suggest that large cancer centers are better. Not necessarily. They are also more often committed to paying off equipment or keeping doctors employed who are trained in old technology. A major barrier to change was allowing oncologists to sell chemo drugs directly to their patients, something other doctors cannot do. You mention MD Anderson and Memorial Sloan Kettering as leaders. My impression ( just my impression) is that MD Anderson is and MSK is not.