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Medical and Pediatric Oncology 31:55 (1998)
Confrontation or Cooperation?
Drs. Sinks and Zarfos, in Notes From Connecticut: A
Surgeon’s Travail, bring forth strongly the continuing
problems inherent in the confrontation between the
health care industry and physicians. They emphasize that
decisions as to what constitutes best patient care properly
rests in the hands of physicians, and not in bureaus—
whether they be in industry or in government. They also
point out that changes in prevailing medical practice
should be made only when rigorous research establishes
the innovations to be in the patients’ best interest, without compromise to safety or satisfactory results, however
The recent report by Warren et al. points up the need
for sound clinical trials regarding these matters [1]. They
provide relevant information concerning outpatient mastectomies, but state that additional data are needed to
resolve the several outstanding issues discussed in their
The concerns discussed by Drs. Sinks and Zarfos are
specific for the United States. The problems could be
recapitulated in other societies, however, where, governmental agencies rather than private companies may seek
to impose restrictions of similar type, if they are not
already doing so.
It might be argued with more than a little justice that
too often medicine must be led if not driven down new
paths. On the other hand, it is clear that procedures and
practices ‘‘honored’’ by years of use and medical authority give way surprisingly rapidly when the advantages of
new departures can be documented by carefully conducted and persuasive clinical trials. A prominent example is the management of cancer of the breast, the
particular entity under discussion by Drs. Sinks and Zarfos. The Halsted radical mastectomy, until a few years
ago the only ‘‘appropriate’’ means of managing a woman
with breast cancer, has given way to alternate therapies
that avoid disfigurement without diminishing cure rates.
Cancer of the prostate is another example. Men have a
choice now between radical prostatectomy and management by hormonal manipulations with or without various
radiation therapy techniques.
It is to the advantage of society as a whole to devise
better means of managing patients that provide dividends
in the psycho-socio-economic sphere without compromising curability. Rather than creating confrontation between the health care industry and physicians groups, it is
quite feasible for the two to work together to achieve
common goals. This can be done through well-designed
studies that would include representatives of both medi© 1998 Wiley-Liss, Inc.
cine and the health care industry in their design, preferably working in conjunction with government through
the National Institutes of Health. These studies could use
the well-established cooperative group mechanisms to
achieve goals that would satisfy the needs of all constituents. There is precedent for this. The Fourth National
Wilms Tumor Study (NWTS-4) was designed to achieve
cost savings through simplifying treatment for Wilms
tumor while shortening the overall course of therapy. The
results have been notably successful. Short, simplified
courses of chemotherapy usually without radiation
therapy (and added cost) have yielded excellent results.
At the same time they have lessened the pressures on
families by making multiple visits over many months
unnecessary, thus decreasing both stress on families and
considerable out-of-pocket expenses. The annual savings
in medical care costs that have resulted plus the ancillary
economies amount to many times the annual budget for
NWTS-4. The National Cancer Institute provided the
funds for this study, but the health care industry has
profited as well, and could well move forward on that
It is entirely practical and desirable that all concerned
should define psycho-socio-economic problems that
could be answered through the cooperative group mechanism, with the health care industry contributing to the
funds necessary for conducting such studies. The research results would lead to decisions reached in conjunction with physicians, and therefore the health care
industry would be less liable to litigation and controversy. At the same time, physicians would gain by providing their patients with proven, simplified, and less
expensive methods of treatment without compromising
the success of therapy. Government would gain in ensuring that the public it represents gets the most at the
least cost to society.
The implementation of this trilateral approach is a
win–win–win situation for each of the three entities—but
the greatest winner of all would be the patient with cancer.
Giulio J. D’Angio, MD
1. Warren JL, Riley GF, Potosky AL et al.: Trends and outcomes of
outpatient mastectomy in elderly women. J Nat Cancer Inst
90:833–840, 1998.
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