An unknown number of cancer patients are dying unnecessarily each year because physicians fail to use the latest and most effective therapies available, the General Accounting Office has concluded in a new study.

The report examined cancers of the lung, breast, rectum, colon, Hodgkin's disease, a lymphoma and testicular cancer. Results showed "that a considerable group of patients among those who had the seven cancers we examined . . . did not receive what NCI {the National Cancer Institute} considers state-of-the-art treatments," the GAO said.

According to the report, 20 percent of those with Hodgkin's disease failed to receive the best treatment. This was also the case for 25 percent of those with one type of lung cancer, 60 percent of those with rectum cancer and 94 percent of colon cancer patients.

"This is especially troubling in that all these treatments have been proven to extend patients' survival in controlled experiments, many of which were concluded 10 or more years ago," the report said.

"I think that they {GAO} have put their finger on an important problem," said Dr. Bruce Chabner, director of NCI's division of cancer treatment. "I don't know how big the problem is, but I suspect it is a problem of considerable dimensions."

From anecdotes, from friends, from patients referred to the NIH, Chabner said, "it is clear that many patients do not get optimal treatment for cancer."

Usually the mistakes are ones of omission: Additional chemotherapy or radiation therapy is not prescribed to destroy cancer cells left behind by surgery, or a full course of a highly toxic drug is not given. In many cases, physicians may fear the consequences of the sometimes lethal side effects. The result, however, is that small amounts of the cancer cells remain in the body to grow again, spreading to distant parts of the body, making future treatment more difficult or impossible.

As Rep. Henry A. Waxman (D.-Calif.), chairman of the House Energy and Commerce subcommittee on health and the environment said recently when he released the GAO report: "Our hopes for the war on cancer were that, through research, breakthroughs in treatment would be found that would extend the lives of cancer patients and hopefully lead to cancer cures . . . The GAO report illustrates that there may be a serious problem in disseminating the results of clinical trials into general medical practice. As a result, thousands of cancer patients may not now be benefiting from the treatment breakthroughs . . ."

It does not mean that physicians are intentionally withholding the best treatments, said Dr. Frank Rauscher, senior vice president for research of the American Cancer Society. "It is not that they know about {an advanced therapy} but are unwilling to use it or not willing to be trained to use it. I would like to think that is not true. It takes time to get the technology out there so it is reliably usable."

Waxman had asked for the GAO study as part of an ongoing analysis of the progress of the country's war on cancer, a disease that claims nearly half a million lives each year and is the second leading cause of death in the United States.

The National Cancer Institute in a report last week showed that over the past 35 years, both the overall incidence and death rates from cancer have increased despite advances in detection and treatment.

To be sure, improvements have been made in patient survival in many forms of cancer, primarily because of advances in medical care from 1950 to 1982. But as another GAO study published last year concluded: "Improvements in patient survival have been most dramatic for the rarer forms of cancer and least dramatic for the more prevalent cancers. As a result, even though the absolute number of lives extended is considerable, this number remains small relative to all cancer patients."

For many years, officials have been concerned that advances in cancer therapy were not reaching patients treated in community hospitals not associated with research facilities.

One of the best examples of this problem involves breast cancer. While there have been raging debates about the treatment of breast cancer -- including whether lumpectomy with radiation therapy is as good a treatment as a modified radical mastectomy (the two are now judged equivalent by most experts) -- there is no question that follow-up chemotherapy should be used after surgery for women younger than 50 whose cancer has spread to their lymph nodes.

Although it should now be standard treatment, "more than one third (36.9 percent) of those women still do not get adjuvant chemotherapy, approximately 10 years after clinical trials proved that adjuvant chemotherapy improves the survival chances of young women with regional breast cancer," the new GAO report concluded.

Chemotherapy for breast cancer should begin soon after surgery, within a month, said NCI's Chabner. "The data is showing us that they either didn't get treatment or the treatment was delayed. In either case that was an error."

What's worse, since 1982, the number of women patients in this category who do not receive the follow-up chemotherapy has been inexplicably on the rise, with up to some 40 percent not receiving the needed treatment.

For some of the other cancers examined by the most recent GAO study, the seriousness of the problem of access to the best care is less clear-cut. The study was conducted by asking the cancer institute for examples of what it considered to be "breakthroughs" in cancer treatment. GAO investigators then used data from NCI's ongoing Surveillance, Epidemiology and End Results (SEER) study, which began collecting cancer statistics in 1972, to find out how many patients received these therapies.

There are limitations in the data, acknowledged in the GAO report, because the SEER statistics used in the study came primarily from hospitals with less information available about therapy received by the patients after they left the hospital.

Still, said Dr. John F. Potter, founder and former director of the Lombardi Cancer Research Center at Georgetown University School of Medicine, after reading the report, "I think that the study was well conducted. It is a very difficult proposition to assess." It was not a perfect study, he said, but "this was a good and meritorious way of assessing the problem."

"In general," Potter said, "the results in this study reflect the opinion of the national oncology community . . . " But Potter said he did not believe the problem was as big as the GAO report suggests.Just why "breakthrough" treatments are not reaching some cancer patients is not clear. "We cannot be sure whether the obstacles to the more widespread application lie with physicians or patients or both or neither," wrote Eleanor Chelimsky, the director of the GAO study.

In addition to the rise in the number of women not receiving follow-up chemotherapy for breast cancer, the number of patients not receiving the "breaththrough" treatments also has been on the rise for small-cell lung cancer and colon cancer.

The situation with colon cancer is a complicated issue, said NCI's Chabner, because the definitive studies proving the worth of follow-up chemotherapy with 5-Fluorouracil (5-FU) have been available for only the last two years. The GAO report, which is based on data up to 1985, does not reflect the growing knowledge among cancer physicians that this technique works.

Still, there had been smaller studies going back several years to show that 5-FU was effective, yet "in the years following 1981, more than 90 percent of patients did not receive any type of chemotherapy as part of their treatments. By 1985, this number had risen to 94 percent," the GAO report said.

Yet many physicians may be simply cautious about using a new therapy. "I think this reflects the skepticism of the national oncology community about this treatment for colon cancer," Georgetown's Potter said.


Large numbers of people could benefit from advanced cancer treatments -- usually adjuvant chemotherapy or radiation -- but are not getting them.