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“You need to make the best decision possible the first time,” says Putnam, an Ingram Professor of Surgery who routinely treats cancers of the chest, including those of the lung and esophagus.
As cancer specialists do throughout Vanderbilt-Ingram, Putnam gets input on individual cases from a multidisciplinary team of physicians, as well as other specialists as needed.
“With that, you have multiple perspectives, multiple therapies available,” he explains, the coordination of which has become integral to cancer care as patient treatment plans often include more than one approach. “I think we do multidisciplinary care here at Vanderbilt probably at a world-class level.”
Both Smith and Putnam point to the importance of highly skilled nurses and other medical staff, as well as up-to-the-minute technology, as imperative for delivering quality cancer care for
every patient.
“If you do something over and over, you tend to get very good at it, very efficient,” says Putnam. That combination can drive down costs while also giving patients more statistical confidence about the care they will receive, he says.
Vanderbilt physicians are accustomed to providing both initial treatment consultations and second opinions, and they understand that many patients will want to know if they can have their treatment just as well close to home.
“Having the appropriate care as close as possible to the family’s home is highly desirable,” says Putnam.
Most patients who come for consultations at Vanderbilt should be able to return to their home community to get their treatment, Johnson says. But, he adds, research suggests that certain cancers – even common, highly curable ones – may be more successfully treated at major cancer centers.
Guidelines emerge to help doctors and patients
The managed care movement that emerged in the 1970s brought with it efforts to better define what tests and treatments were proven effective for specific conditions. While there have been drawbacks associated with managed care, the movement did usher in a growing focus on evidence-based medicine, the concept that best practices can be defined by looking to research results and, in some cases, expert consensus.
Cancer doctors and their patients have some very specific guidelines to consult when considering treatments and timelines. The National Comprehensive Cancer Network (NCCN), a consortium
of 21 of the world’s premier cancer centers including Vanderbilt-Ingram, has developed free Web resources for both clinicians and patients. The guidelines detail best-practice treatments for the cancers that affect 95 percent of all patients.
“We hope it will end up with better care for patients, and I think it will,” says Joan S. McClure, M.S., who is responsible for the NCCN guidelines as the network’s senior vice president of clinical information and publications.
Other diagnosis and treatment information is available from the NCI, the American College of Surgeons and ASCO.
NCCN’s guidelines are developed and regularly updated by panels of different specialists from the 21 member centers. This multi-disciplinary approach aids in the coordination of care from one cancer specialist to another, McClure said, noting that treatment “decision trees” may apply to as many as 85 percent of patients.
“In every practice there are going to be patients who don’t fit the guidelines,” she explains. “If a practitioner is slavishly following the guidelines regardless of the situation, that would not represent good quality care.”
The biggest barrier to defining quality cancer care may be that people have trouble pinpointing what to measure, Johnson explains. While some want to focus on process measures – what is done and when it is done – others suggest that patient outcomes – how people fare after treatment – ultimately are most important.
“It’s a very big and challenging problem” for which gathering evidence is both time-consuming and costly, he says.
For patients, the availability of guidelines can be a source of comfort as they consult with doctors about their own specific diagnosis and treatment options. Ultimately, though, those guidelines must be taken into account with other factors, and the best care will be individualized, Putnam says. “We take care of patients one at a time,” he says. “I tell patients that together we will make a good decision – we will make the best decision for you.”
Look for survivor support
With more than 10 million Americans living today with a history of cancer, it’s clear the disease is an everyday factor in the lives of many people. However, providing ongoing monitoring and follow-up care for these patients is a relatively new and growing challenge for the medical community.
“We know that people who have had cancer are at risk for other disease processes,” not only a recurrence of cancer, but also other problems caused by cancer treatments, explains Johnson.
Vanderbilt-Ingram provides support through a comprehensive survivorship clinic and through patient education and outreach programs, including partnership with programs including the American Cancer Society and Gilda’s Club Nashville. But Johnson says the hope is that physicians in training today will learn more about how to provide proper monitoring and follow-up care for survivors, especially as their numbers are expected to balloon as the oversized baby-boom generation moves into old age, when cancer becomes more common.
“We definitely provide this at Vanderbilt, but our view is this should not be a service that is unique to us,” Johnson says. “It’s a good problem (caring for long-term survivors), in a bizarre sort of way.”
Recognizing the challenges facing cancer survivors, several
medical sources have developed in-depth information and guidance. These include ASCO’s People Living with Cancer Web site, www.plwc.org, and the NCI’s cancer survivorship Web pages, www.survivorship.cancer.gov.
As for the future of the quality of cancer care in America, Johnson says he’s optimistic that over time it will get better and more consistent for all those who need it.
“However, I think it will be evolutionary, not revolutionary,” he observes. “It’s going to take time.” 
Vanderbilt-Ingram has created a Web site to help patients navigate their cancer choices at www.vicc.org/choose.
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