The Role of U.S. Cancer Centers in Global Cancer Care

The role of U.S. cancer centers in global cancer care is highly dependent on the philosophy of the cancer center. Individual philosophies range from the ‘‘stand alone’’ focus on leadership, research and translation, superb home institution care, and education through high quality efficient ‘‘standard of care’’ practice to aggressive international marketing looking for a ‘‘franchise’’ model. Many have components of all three. This creates the debate as to the role of U.S. cancer care in serving the needs of global cancer care. The roles are reflected by two very different approaches. One is providing access to U.S. cancer care to patients from developed nations and the other providing physician access from developed, underdeveloped, or developing nations. The former tends to be either the provision of leading cancer care to a small minority of affluent patients looking for pinnacle care or the belief that U.S. cancer care can be exported and delivered, preferably for profit. The latter is physicians, the majority of whom look to an educational experience superior to that available in their own countries. Problems exist in both of these approaches. First, only affluent patients are able to get access to personal cancer care in the United States, by either ‘‘self-pay’’ or by buying U.S. health insurance. Second, the efforts to export cancer care are belabored by problems of cancer care delivery. In the case of physician experience, the vast majority, whether from developed or developing nations come wanting to be absorbed into the U.S. mosaic. Neither approach improves global cancer care. A driving force is the assumption that U.S. cancer care is the best in the world. It is true that some of the best cancer care in the world is available in the United States. Such care is, however, not available to everyone, which is reflected in the significant underinsured population and the extraordinary expense of cancer care in general. Why is U.S. cancer care so expensive? It can be readily summarized by: we overdiagnose, e.g., ductal carcinoma in situ; we overinvestigate for no benefit, e.g., magnetic resonance imaging in early-stage breast cancer; we overtreat, e.g., uniform application of radiation therapy to ductal carcinoma in situ based on randomized, control trials of limiting local recurrence but no survival benefit. In addition, we treat for minimal benefit, e.g., treatment of pancreatic adenocarcinoma where benefits are measured in days to weeks. More importantly and frequently neglected, when we treat for minor benefit we ignore consequences, side effects, or cost of such treatment. In randomized, clinical trials, once a statistically significant improvement is established no matter how small, that trial becomes standard of care for all patients with the diagnosis for which the trial was designed. We ignore the fact that clinical trial results are only applicable to those that entered the trial. This latter approach expands treatment to many who cannot possibly benefit either because they were never going to recur or die, or recurrence or survival was not impacted by the trial. Some patients were never going to recur and others did recur despite the intervention. Such an approach markedly increases the cost of overall care for minimal benefit. Attempts to export such outcomes globally are inappropriate at best. The ultimate challenge is that the cost of current U.S. cancer care is not sustainable in the United States or anywhere else. In the United States, we compound cost by elevating charges designed for maximum reimbursement rather than for actual cost-effective, associated benefit. Is that the global cancer care we would wish to export? This author would strongly argue against that concept. Many healthcare systems in the United States would disagree with that philosophy and believe that we should be Society of Surgical Oncology 2015