‘How long do you take to perform this procedure / operation?’ - a question that I am frequently asked by patients and relatives in Singapore. Why? I wondered. To gauge the complexity of the procedure or to plan how much time to set aside to accompany the patient? Or it is really used to gauge how good the doctor is?  The shorter the time, the better the doctor. Is that a good indicator?

Let us take colonoscopy as an example. Colonoscopy has been shown to be an important and effective preventive procedure for colorectal cancer (CRC). It has been shown that endoscopists who take a longer time to withdraw the scope during endoscopy achieve a higher rate of adenoma polyp detection. (Adenoma polyp, if left untreated, will evolve into colon cancer over time.) Several studies have been done to look at which processes constitute good colonoscopy practice. However, few have been carried out to look at what parts of the practice affects patient outcome. For example, does the type of endoscopist and the setting where the procedure is performed influence patient outcome?

A recent study from University of Toronto studied individuals in Ontario diagnosed with CRC between 2000 and 2005 (Gastroenterology 2011; 140: 65 -72). The researchers determined how many of these individuals with cancer had had complete colonoscopies 7 to 36 months before the diagnosis. These patients were defined as having developed a post colonoscopy colorectal cancer (PCCRC). The researchers then determined if endoscopist factors, such as volume of endoscopy, polypectomy and completion rate, specialization and setting where the procedure was carried out, were associated with PCCRC. A total of 14,064 patients had had a colonoscopy within 36 months. Of these, 1260 (8.95%) had developed a PCCRC. Patients with a proximal cancer were more likely to have a PCCRC than patients with distal cancer. Non-surgeon and non-gastroenterologist endoscopist is associated with PCCRC. When the colonoscopy is performed in a non-hospital based setting, it is associated with PCCRC. Patients undergoing colonoscopy performed by an endoscopist with a completion rate of ≥ 95% were less likely to have a PCCRC than those patients who had colonoscopy by an endoscopist with a < 80% completion rate. For proximal PCCRC, endoscopists with a polypectomy rate ≥ 30% were less likely to have patients with PCCRC. The volume of colonoscopies performed by an endoscopist had no influence on the PCCRC rate.

To me, the study shows that the training of the endoscopist and how meticulously he performs the procedure will impact significantly on the outcome. To be meticulous you cannot be hurried. If you do not want to be hurried, you will take more time to complete the task.

My standard answer to the question ‘How long do you take to perform this procedure / operation?’ is “It will take as long as it is necessary to do a good job”. I will, howeve,r tell the patient a time range but I cannot be precise about how long the procedure will take.

I have had patients who moved onto a different doctor because ‘my time’ is longer than the other doctor’s. A patient has rights and the choice is his / hers.

Over the last couple of years, the cost of everything has increased appreciably. Health care costs are no different. In an ideal society, the cost of providing health care would be borne in full by the State. Whenever a new drug or a new test was discovered, it would automatically be made available to the masses at no cost to the individual. Unfortunately, we do not live in a Utopian society. Managing ever increasing health care costs is a constant headache for all societies.

A recent study from the College of Pharmacy, Union University in Albany, New York, examined the variations in oncology treatment cost in patients with colorectal cancer (Am J Manag Care 2008; 14: 717- 725). From a nationwide registry they looked at the chemotherapy regimen used in 421 patients with colorectal cancer. The most common regimens were 5-fluorouracil-leucovorin calcium (5-FU/LV) in 147 patients (34.9%), fluorouracil-leucovorin-irinotecan hydrochloride (FOLFIRI) in 111 patients (26.4%) and fluorouracil-leucovorin-oxaliplatin (FOLFOX) in103 patients (24.5%). The total costs for 6-cycles of the commonly used regimens are shown in the following table. The largest cost differential was US$35,971 between FOLFIRI and 5-FU/LV.

Total Cost of 6 Cycles of Commonly Prescribed Treatment Regimens

The above study finished at the end of 2005 and thus did not assess the impact of using monoclonal antibodies such as cetuximab (Erbitux) and bavacizumab (Avastin) as part of the chemotherapy regimens. If these agents were included, the cost would be significantly higher than US$38,027!

The above study highlighted the fact that, even within USA, the chemotherapy regimen used for treating colorectal cancer varies. While 5 FU/LV is an effective regimen, some oncology centres would only use the FOLFIRI regime in order to improve the survival figure. The cost difference between the two is 38 times but is the survival difference between the two regime 38 times as well? The answer is no.

Given a limited budget to deliver health care to the community, the government has to decide which regimen gives the best bang for the buck. Thus, a government may decide that 5FU/LV is the only chemotherapy regimen available to all patients and the additional cost associated with the use of FOLFIRI / FOLFOX regimen is ‘not worth it’. For patients who are seeking private health care, cost may be an even bigger issue. When a patient is told that FOLFIRI is better than 5 FU/LV, he / she would naturally want to choose the FOLFIRI regimen despite a 38 times difference in cost. What patients are seldom aware of is that by paying 38 times more you are not assured a 5 years survival that is 38 times better.

The survival benefit of the FOLFOX and FOLFIRI regimens are very similar but yet the price difference is 100%. Whether you pay US$17,584 or US$38,027 for a 6-cycle treatment regimen is up to the personal preference of your oncologist and to some extent yours. (FOLFOX is the preferred regime in Europe because oxaliplatin (OX) is a ‘European drug’. FOLFIRI is the preferred regime in USA because irinotecan (IR) is an ‘American drug’.) If you are paying for your chemotherapy, you should be fiven full cost information on and survival benefit associated with the various chemotherapy regimen. Your oncologist can explain to you his preference and recommend to you what he thinks is the most suitable regimen. If the benefit is similar, the decision as to whether you spend US$38,027 or US$17,584 for 6-cycles of treatment rest solely with you. The question you need to answer is ‘Is it worth it’. In order to answer that properly you need to be fully informed.