The Tribune

Bahamians should not think travelling abroad for cancer treatment is necessarily the best plan. Dr Tom McGowan explains why . . .

TODAY is World Cancer Day, with the theme “We Can I Can”. This is an important day, because it asks us to think about what cancer means to us as individuals and to us as a community.

There are a number of topics within in this theme, but one is to reduce the impact cancer has on individuals and families. We need to remember that cancer affects more than just the person diagnosed with it, and that recovery from cancer is more than just medical treatment.

True recovery means that the patient recovers in mind, body and spirit. I believe one of the barriers to true recovery is when cancer patients leave home, and go abroad to face this on their own. This fragments their care, it takes them from their family and spiritual support system, and it interferes with their ability to work.

When I first moved to The Bahamas from Toronto a year and half ago to practice as a radiation oncologist I expected there to be some differences in the practice of oncology. I knew there was a higher incidence of the breast cancer gene, that prostate cancer screening wasn’t widespread, and that cervix cancer tends to be more common and more advanced than Canada. I hadn’t practised outside Canada, so I wasn’t entirely sure what the structure of the practice of medicine would be like. I expected high quality, and I wasn’t disappointed.

The medical and radiation oncologists and surgeons I’ve met and worked with here are well trained, knowledgeable, experienced and hard working. Case conferences are held every Friday, in which the management of patients is discussed. Any of the new targeted agents that medical oncologists use are available here. The radiotherapy centre is well-equipped and able to deliver IMRT (Intensity Modulated RadioTherapy). Other than a few exceptions, like the need to travel off island for a PET scan, all the elements are in place for patients to receive world class, state-of-the-art treatment at home.

Given this, I was very surprised to learn how common it is for Bahamians to feel they need to travel to the US for cancer treatment. This was particularly hard for me to understand because for three years in the 90s, waiting times in Ontario (Canada’s largest and richest province at the time) for radiotherapy exceeded two months and patients were forced to leave Ontario for treatment. This was a crisis. Patients were up in arms that they needed to leave their family and home, not be able to work, and be alone during one of the most difficult times of their lives.

There’s no waiting time crisis here, and the sense of community and family is stronger here than in Canada, so the decision to leave home has to be driven by a belief that the care is so much better in the US that it’s worth any sacrifice.

But this belief doesn’t match what I’ve seen.

There will be some exceptions with rare diseases, but those aside, patients don’t always get better care in the US. They might get more invasive or more complicated care than what they were offered here, but that doesn’t mean it’s better. When someone travels for a second opinion, and that opinion makes that person question whether the right treatment was offered to them at home, it raises doubts in their mind. When people feel their life is at stake, this type of doubt can be intolerable.

I’ve seen this doubt raised on more than one occasion by an MD in the US giving a second opinion on the care offered by a local specialist, when my opinion supported the local decision, not the second. A second opinion is just that – an opinion. It should be taken as such. To help sort this out, when a patient gets a second opinion, they should discuss it with their first MD, to try to understand why there’s a difference.

Access to better technology, or the latest drug therapy, is sometimes raised as an issue in favour of the US. In my field of radiation oncology, we aim to maximise the dose to the cancer and minimise the dose to the normal tissues. It’s both as complicated and as simple as that. What needs to be understood is whether the equipment being used is capable of delivering the appropriate treatment.

The radiation facility in Nassau is more than capable of delivering what’s needed in the vast majority of cases. When a US facility claims to have a piece of technology that’s not here, the question should be how does that device improve my outcome? With respect to systemic therapy, I don’t know of a drug or agent that isn’t available here. Our local group of medical oncologists have access to the advanced therapeutics that are starting to fundamentally change how some cancers are treated.

I have a concern that patients who travel elsewhere for care are not just travelling unnecessarily, but they’re compromising the quality of their care. For example, with breast cancer, it’s common knowledge here that there’s a higher incidence of the breast cancer gene in The Bahamas. This was first reported by Bahamian oncologists who studied this based on their observations. This knowledge is now part of day-to-day decision making here for breast cancer patients.

This specific issue regarding Bahamians wasn’t something I was aware of before I arrived and, I suspect, it’s not something physicians who perform second opinions elsewhere are aware of. The point is that having knowledge of, and experience with, local patterns of disease is an advantage for the patients being treated locally.

What does quality of care mean?

Quality of care has many dimensions. The first determinant is whether or not the cancer was treated properly. That is, whether the right decision was made, and whether it was carried out properly. The second determinate is whether or not the patient was treated properly. That is whether the care was patient-centred or not.

Was the cancer treated properly?

A patient can help ensure the right decision is made by requesting a multi-disciplinary assessment prior to surgery. A multi-disciplinary assessment means consultations with both a medical and radiation oncologist, as well as the surgeon. This helps the patient be certain that all options are considered. This multi-disciplinary assessment can be done on island and, in fact, in my opinion, is more important than a second opinion with another surgeon in the US. In addition to this multi-disciplinary assessment, the case can be discussed at a case conference, which increases the number of people who can discuss the case. With this approach to decision making, patients can be confident the right decision is made. This approach is more often what’s being done now.

Was the patient treated properly?

The Picker Institute in the US has defined eight dimensions of patient-centred care. These are critical to the best outcomes for patients. When patients leave home for their care, some of these are unavoidably compromised, and others are harder to achieve.

1. Respect for patient’s values, preferences and expressed need
2. Co-ordination and integration of care
3. Information, communication and education
4. Physical comfort
5. Emotional support and alleviation of fear and anxiety
6. Involvement of family and friends
7. Transition and Continuity
8. Access to Care

When someone reads this list, they can decide for themselves which are harder to achieve when they leave, and easier to achieve when they’re being treated in The Bahamas by someone who lives and works in their community, and surrounded by friends and family. Where their values and experiences are the same as the people they’re being cared for by.

One aspect I’ll discuss directly. Dimension 7 - Transition and Continuity - refers to what’s also called survivorship, or how a patient is managed after they’ve finished their care. Being treated locally means that, when issues arise, patients can be seen by the team that treated them, which is important. There is a growing recognition that survivorship is critical to long term outcomes for patients. Splitting care between two countries makes this hard to do well.

In the year and a half I’ve been living and working here, I’ve started to develop an understanding of some of the reasons insured Bahamians go off island for cancer treatment. I’ve been told that the two biggest reasons are the feeling that we don’t have everything needed to deliver the highest quality care and privacy concerns. As far as the first issue goes, the simple answer is that there is everything needed to treat the vast majority of conditions to the highest quality. Regarding the second issue, privacy is a personal issue, and one that each person needs to come to grips with.

However, having cancer is not the taboo diagnosis it once was. In years past, it was very common for patients to not be told their diagnosis for fear of upsetting them. We know now that this isn’t healthy for the patient or their family. We know that having a strong support system helps people recover. Having friends and a family around to support patients matters, and leaving takes that away from you.

Those historic reasons don’t match the current reality of a highly trained, skilled, experienced medical community involved in the care of cancer patients. Oncology care isn’t perfect here, but it’s not perfect in the US, Canada, the UK, Australia, France, Sweden, or anywhere you look. Patients need to make the best decisions for themselves, based on their own circumstances. To help decide what to do, individual patients need to ask the following questions:

1. Will the right decision be made?
2. Can the treatment be carried out properly?
3. Will the care I receive be patient centred, and will it reflect what I need?

Based on those questions, I don’t see why patients leave. Good marketing doesn’t equal better care.

Dr Tom McGowan MD, MBA, FRCPC is the

Director of The Cancer Centre Bahamas, a full service comprehensive

cancer centre at The Medical Pavilion Bahamas, Collins Avenue. It has provided clinical services to The Bahamas since 2004.