In a new book, prominent oncologists Philip A. Salem, MD, Director Emeritus of Cancer Research at Baylor St. Luke’s Medical Center in Houston, Texas, and President of Salem Oncology Center, a private cancer medical facility located in the Texas Medical Center in Houston, Texas,?provides a detailed roadmap to help people who have recently been diagnosed with cancer.
Salem, who served for more than 5 years on a White House Healthcare Advisory Committee under Presidents George Herbert Walker Bush and William Jefferson Clinton, advises patients how they can best confront their disease. But he also advocates for a better patient-doctor relationship, insurance reforms and the elimination of burdensome regulations in healthcare.
A controversial statement
In an interview with Onco’Zine, Salem started by arguing that doctors should have the liberty to treat patients as they thinks best, and that they should be able to practice medicine without fear of litigation for failure to comply with, what he calls ‘arbitrary,’ standards and guidelines that may not always be appropriate for every patient. He is convinced that excessive and unnecessary regulatory requirements and insurance demands make doctors less flexible and effective in treating their patients.
“As a result of the ominous threats posed by the legal system, doctors are becoming increasingly occupied with protecting themselves against the [legal] repercussions that may confront them rather than doing what is best for their patients,” Salem stressed. “This means that they have to spend a lot of time trying to comply with rules and legal matters rather than caring for their patients.”
“The sad thing is that insurance companies interfere at every level of diagnosis and therapy and, as a result, negatively impact the medical decision-making abilities of physicians. In reality,” Salem emphasized, “insurance companies, aided by our government, are doing their best to destroy medicine.”
…on the surface, this is a controversial statement!
His biggest concern is that the commercialization of medicine, the pressures of regulatory overreach and the possibility of litigation, erode the quality of care and, in turn, the trust between the medical team and the patient.
“The ultimate objective of insurance companies is ‘saving money’ instead of ‘saving lives.’ This contrast with the ultimate objective of doctors aiming to cure or – at least – trying to improve the health of their patients. These two objectives are difficult to reconcile,” Salem contends.
“I realize that, on the surface, this is a controversial statement, but the reality is found in insurance payment restrictions on practitioners to independently decide what the best treatment for his or her patient is. This leads to a practice of defensive medicine to avoid being sued. This, in turn, is counterproductive to individualized, sensitive and compassionate care.”
‘Re-humanizing’ cancer treatment
Salem’s believes that in the practice of medicine doctors should treat people, not diseases. He therefore tries to ‘re-humanize’ cancer treatment.? “Re-humanizing care begins,” Salem explained, “with building a better working relationship between a patient and his or her medical team.” And according to Salem, this starts with access.
“Patients must [always] have easy access [to their medical team],” he said. “I mean 24 hours a day, 7 days a week, 52 weeks a year [easy access] to their doctor, oncology nurse and every healthcare professional taking care of them. But unfortunately, access has, in many cases, been significantly hampered,” he added.
In ‘re-humanizing’ cancer treatment Salem also believes that in addition to proper medical interventions, patients need love, care, hope, compassion and have the ability to talk about their fears, anxiety and concerns.? This leads to building trust between the medical team and the patient.
“It’s crucial to establish a bond of trust between patient and doctor. Without such a bond, it’s very difficult for a patient to win their fight against the disease,” Salem explains.? “My motto is: ‘In cancer medicine, a doctor who does not love his patient cannot cure him.'”
In his book, Salem explains that patients could benefit from supportive therapy but don’t always receive this.
“Supportive care is the kind of treatment that allows patients who are receiving anticancer agents to either abort the treatment or significantly reduce the toxicity of treatment.? This may increase the health related Quality of Life of a patient,” Salem explained.
“But it is extremely difficult to do this because supportive therapy is usually not covered by insurance. And this means that the majority of patients in our country do not receive this kind of treatment,” Salem added.
“The result is? – and I like to emphasize this – that severe treatment related toxicity may be the result, leading to patients stopping treatment. The consequences can be disastrous.”
Standard therapies, also called best practice or standard of care involves treatment that is accepted by medical experts as a proper treatment for a certain type of cancer and is widely used by healthcare professionals. In the treatment of cancer this may include surgery, radiation therapy and chemotherapy. Salem asserts that the idea of standard of care – and misconceptions of it – have harmed patients.
“The concept of standard of care has restricted the delivery of more advanced and sophisticated treatments. I strongly believe that a patient should receive – what his or her physician believes is – the best treatment option, whether this treatment is considered standard of care, or not.? Unfortunately, physicians may be challenged by complicated procedures and the fear of litigation – making them want to avoid what they perceive as risk,” Salem noted.
“As mentioned earlier, the power of insurance companies results in practitioners following the standard of care mandated by insurance companies.? But unfortunately the ‘standard of care’ may not necessarily mean the ‘best possible treatment.’? In fact, it’s my opinion that among the most efficacious treatment options, ‘standard of care’ could be considered the least effective.”
Right to live
Salem believe that the most important and sacred human right should be the right to live.
“This can only be achieved if we make the right to healthcare the most important and sacred human right. Consequently, I believe that the Charter of the United Nations should be changed to emphasize this right. In reality, all human rights listed in the UN Charter fade in significance compared to the right to live,” Salem said.
Truth and nothing but truth
Compassionate care depends on effective bidirectional communications between patient and physician. But communication is often challenged when a patient withholds or distorts, information that is crucial to the doctor-patient relationship and effective treatment. In turn, what doctors tell – or do not tell – a patient also matters greatly to their patients.? Salem implores doctors to be truthful when talking with their patients, while, at the same time, being sensitive and compassionate.
“I understand that it is extremely difficult to tell the truth effectively, constructively and without traumatizing the patient. But it is possible,” Salem said.
“Let me give you an example. Let’s consider a really bad scenario: You have a 55-year old pancreatic cancer patient.? As a trained physician, you know that the median survival from the time of diagnosis to death is arguably the worst of any of the major cancers. For untreated advanced pancreatic cancer, the median survival is about 3 1/2 months.? However, with good treatment survival may increases to about eight months – and of course, some patients may live much longer. You’re truthful if you tell your patient that he has one of the worst cancers, that treatment is usually not successful and that most patients are expected to die within less than 2 years after being diagnosed. But if you do this, you’re not just telling the truth,” Salem notes. “You’re probably traumatizing your patient as well. While truthful, such an approach is harsh, unkind and very blunt. And your patient may feel like you’ve just pushed him off a cliff..,” he added.
“But you can also tell your patient the truth in a different way. The fact is that your patient has a serious medical problem. Instead of saying that he is going to die soon, you may say something like: ‘We don’t have a cure, but treatment can hold the disease down for a long time…’ and that ‘the goal is to prolong life as much as possible…,'” Salem explained.? “You may want to add something reassuring, by adding that he is really fortunate that he has come to you at the time when medicine has new and innovative treatment options and that these novel approaches may give him a change for to live’,” Salem further said.
“Of course, both versions are truthful,” Salem clarifies. “However, one is compassionate and hopeful and the other traumatic and pessimistic,” he added.
Salem understands that honest and truthful conversations about a patient’s mortality are complex and very difficult.
“Helping a patient to understand the possibilities and limitations of medicine – especially in the treatment for cancer – is hard. And as doctors we often make the mistake that we try to find out how a patient wants to be treated. But we often forget that beyond managing the patient’s disease, the as best thing we can do is to help him deal with the overwhelming anxiety caused by the disease. That’s real compassion. But this involves treating the patient, not just the disease. However, such an approach requires as much listening as talking…,” Salem observed.
Complementary and Alternative Medicine
Complementary medicine generally refers to interventions that are generally not part of conventional medical care but are delivered alongside or in addition to ‘standard of care.’ In contrast, alternative medicine replaces the ‘standard of care’ with other approaches that may include supplements and diets, lifestyle changes, ‘natural’ medicine and sometimes other non-western interventions and approaches to health and healthcare.
Salem said that he is a believer in complementary treatment but that it is important to make sure that these treatments are not harmful.
“Complementary treatments do not interfere with proven medical treatments, they are an addition to, not instead of, medical treatment. If we know that these treatment options are not harmful, I have nothing against them. The most important thing is that patients must receive the best scientifically base medical treatment available to him or her. And complementary treatment may make standard treatment less toxic and better tolerable. For example, complementary treatments such as acupuncture may help lessen some side effects of cancer treatment such as nausea and vomiting associated with chemotherapy.”
But Salem makes clear that he does not believe in ‘alternative’ treatment.
“I believe that proper cancer treatment should always be based on scientifically proven medicine. And so-called alternative treatment can never be an alternative option to proper treatment. Hearsay is not science. It’s not evidence of efficacy, and should never be considered,” Salem explained.
“But the role of diet an nutrition is important, albeit not as important as the popular press and social media may make them out to be. Sure, patients should have a good diet and proper nutrition, but I like to emphasize that contrary to what some media outlets may suggest, diet and nutrition alone cannot cure,” Salem said. “Cure can only be achieved by a proper, science based, medical treatment.”
What it takes to ‘Win the War’
The signing of the National Cancer Act of 1971 by United States president Richard Nixon is generally viewed as the beginning of ‘War on Cancer.’ The act granted broad authority to the Director of the National Cancer Institute (NCI) to plan and develop a National Cancer Program that included the NCI, other research institutes, and other federal and non-federal programs.? While much of the progress made over the last 40+ years can be directly attributed to research made possible as a result of the National Cancer Act of 1971, Salem notes that it is our human spirit that may help us win the war.
“It takes courage, perseverance, hope, compassion and of course an excellent, science based approach to medicine that helps us to truly win the war on cancer,” Salem concluded.
Salem PA. Defeating Cancer: Knowledge Alone is Not Enough. Quartes Books, Hardcover. 148 pages. ISBN: 9780704374522.
Disclaimer: The views and opinions expressed in this article are those of Philip A. Salem, MD and do not necessarily reflect the official position of Onco’Zine or the publishers of Onco’Zine.
Last Editorial Review: November 2, 2018
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