Medical and Pediatric Oncology 31:55 (1998) EDITORIAL 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 measured. The recent report by Warren et al. points up the need for sound clinical trials regarding these matters . They provide relevant information concerning outpatient mastectomies, but state that additional data are needed to resolve the several outstanding issues discussed in their article. 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 model. 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 Editor-in-Chief REFERENCE 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.