DiaLog: Rethinking the Standard of Care

From OncoLog, October 2007, Vol. 52, No. 10

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Rethinking the Standard of Care

Michael Fisch, M.D., M.P.H.,
Director, General Oncology Program; Associate Professor, Department of Gastrointestinal Medical Oncology; Chair, OncoLog Editorial Board

The “standard of care,” as defined by the dictionary, is “a diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.” It is easiest to identify for any medical process that is both readily available and appears to be entirely satisfactory as it currently stands, and when there is widespread agreement that innovation is not needed. For example, it is the standard of care to insert a catheter into a vein for any patient who requires intravenous fluids or the administration of intravenous medications.

In contrast, the standards of care for cancer patients are often difficult to discern, challenging to apply, and surprisingly variable based on the location of care—and they can have devastating limitations for some patients.

Consider the standard of care for advanced pancreatic cancer, a deadly disease with a median overall survival in the range of 2 to 6 months. This grim fact is not substantially different than it was 15 years ago, despite the development of newer chemotherapy options. The standard of care is thus disappointing for most patients with pancreatic cancer. For other patients, the standard of care may not even be an option because it is too costly or not available in certain regions or health systems.

The standard of care could be seen more as a space than as a point. It reflects care that is in general accord with the patient and family’s wishes and is also reasonably consistent with local clinical, cultural, and ethical standards. The standard of care is to be identified and acknowledged. But when it is associated with outcomes that are too limited, we need to offer our patients the opportunity to escape from it.

The key to this escape is to strive to get beyond the potentially devastating limitations of the standard of care, making certain that there is innovative, carefully monitored, expertly conducted clinical research that provides patients in all settings with a superb clinical trial to contrast with the standard of care. Patients also deserve clinical trial options for nausea, pain, distress, and other difficult problems.

Trials are, of course, filled with uncertainty. But so long as care occurs in an envelope of compassionate clinicians working in an effective team along with a plan for continuous quality improvement, there is reason to be hopeful.

For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.

Other articles in OncoLog, October 2007 issue:

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