The patient is in the doctor’s hands. They will trust you to do anything at all. You must use good judgment and restraint.

Bill Cook, MD

Cancer is many diseases, and cures are elusive. Slow-growing tumors rarely require treatment because most never cause problems and may go away on their own. Fast-growing tumors are discovered too late to do anything. Only cancers of intermediate growth rate, a minority, have the potential for worthwhile intervention.

 For most tumors, a modest life extension is the best we can do. Exceptions include metastatic melanoma, renal cell cancer, a few lymphomas, leukemias, and testicular cancers. Chemotherapy may extend life or sometimes cure these. Small numbers prop up the bulk of the other treatments, and careful analysis shows that the expenses and toxicities may not be worth it. 

Dying patients reach for anything. People with cancer are tremendously vulnerable and have an overwhelming need to trust caregivers. They continue to believe in their doctors, almost regardless of the circumstances. 

Oncologists always have new, toxic, and expensive drugs. They may have seen a few patients survive long-term using some medication that rarely works and makes everyone sick. They have read studies that showed (maybe) two months’ average increased survival with certain drugs. They can usually tell the patient that there is a costly chemo that might help, and it is covered by Medicare or insurance. 

It is a demanding job, and the oncologists have a terrific financial conflict of interest that makes it harder. They retail chemotherapy infusions for about a 20 percent markup. Inside the specialty, they call this “buy and bill.” By 2013, 65 to 70 percent of oncologists' income was drug charges. Their pay doubled from 1995 to 2004, when it was $335,000, and then it went up again to $445,000 by 2017. 

Drug representatives stay in touch with oncologists and let them know whether they are “making their quotas.” The companies offer doctors higher percentages for certain drugs if they order more. This is an inducement to raise the doses of drugs, which can be harmful. In one egregious case, medications were promoted in this fashion to treat anemia that also increased the chances of premature death. Their sales were $37 billion between 1996 and 2009. Otis Brawley, in How We Do Harm, said, “[These] drugs were not used to cure disease or make patients feel better. They were used to make money for doctors and pharmaceutical companies at the expense of patients, insurance companies, and taxpayers.” 

If two physicians made a deal like this between themselves, prosecutors might throw them in prison. “Fee-splitting” is a similar, perhaps nearly identical crime where a physician kicks back a commission to another doctor for a patient referral. Federal Stark laws applying to Medicare and Medicaid plus many state laws impose criminal penalties for this. (Between lawyers and realtors, however, referral fees are accepted practice.)

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