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Perspective
Practicing Western Oncology in Shanghai, China: One
Group’s Experience
By David H. Garfield, MD, Harold Brenner, MD, FRCR (Lond), and Lucy Lu, RN
ProMed Cancer Centers–Shanghai, Shanghai, People’s Republic of China
In October 2011, we—David H. Garfield, MD, medical oncologist,
United States; Harold Jacob Brenner, MD, FRCR,
radiation oncologist, Israel; and Lucy Lu, oncology nurse,
Shanghai, China—were part of a group that opened the first of
planned multiple outpatient cancer centers in China, offering
radiation therapy, chemotherapy, and imaging, including magnetic
resonance imaging (MRI), computed tomography (CT),
ultrasound, and mammography. Although we had previously
researched oncology in China, we were still in for a great many
surprises.
The Chinese and Their Doctors
Mainland Chinese attitudes are different from what we are
accustomed to in the West. There is a lack of trust between
patients/families and physicians, related in part to there being
few urban general practitioners, resulting in no long-standing,
physician-patient relationships. There is a feeling that care is
being provided for personal gain, much more so than in the
West. When individuals are ill, or think they may be, they go
directly to hospitals, including traditional Chinese medicine
hospitals, rather seeing a non–hospital-based practitioner. Care
is received almost entirely in hospital; this is the main way
physician-patient relationships develop.
If patients receive chemotherapy once per week, or radiation
therapy 5 days per week, patients happily remain in hospital full
time, which is especially appealing when they are bedded on
VIP floors or during monsoon seasons. This may last longer
than 1 month, during which time they are housed and fed.
Chinese Oncology
As an example of unintended consequences, the government
has made it inexpensive to see physicians. This has led to a
general complaint about medical care in Shanghai: the limited
time physicians spend per patient. We know an excellent surgical
specialist who sees up 40 patients within 2 hours, meaning
approximately 3 minutes are spent with each, at a cost of approximately
$40 per patient. For $3.50 each, 80 to 100 patients
are seen during 4 hours by that same physician on another day.
During those few minutes, rarely is a physical examination performed.
Several questions are asked and answered, with a brief
look at images and laboratory tests, tumor markers, and so on;
that is it.
Lucy Lu: A woman with estrogen receptor–positive breast cancer,
whose mother died as a result of breast cancer and possible
treatment-related heart disease, stopped taking tamoxifen after
2 weeks for fear of the adverse effects about which she had read.
Our Western oncologist convinced her, after much discussion,
to continue tamoxifen by telling her the most important thing
was to be alive for her 4-year-old daughter. She called back later
and said she really appreciated what we did for her because her
Chinese physician had just given her the pills, not caring
whether she risked her life by not taking them.
Drs Brenner and Garfield provide physical examinations at
nearly every patient visit. They get medical information and
communicate with the patient. For example, a woman who
underwent surgery for breast cancer had, unknown to her surgeons,
recent hyperthyroidism, noted only by Dr Garfield, who
felt this could have made the cancer grow faster.
Patients, Physicians, and the Party
Chinese patients, thinking they have or are diagnosed with
cancer, will demand that certain tests be performed. Physicians,
rather than argue necessity, will acquiesce instead of having
these patients complain to hospital administrators, when they
must then defend their case. In this regard, it must be pointed
out that hospitals have two administrators: first, a conventional
one, as in the West, and second, a Communist party member. A
physician must take care. A bad outcome is felt to put physicians,
particularly surgeons, at risk for administrative admonishment,
lawsuits, or, worse, bodily harm.
Lucy Lu: Chinese physicians order many kinds of blood tests
for patients, often treating numbers instead of diseases. The
increase or decrease of tumor markers frustrates both physicians
and patients. Our Western oncologists, however, pay more attention
to how the patient feels, physical examination, and/or
imaging, instead of tumor makers.
Respect for Lives
Lucy Lu: Our Western physicians take difficult cases as challenges,
whereas Chinese physicians first assess risk to themselves
and hesitate in helping patients. We saw a 55-year-old patient
with lung cancer who was refused treatment for severe hemoptysis
by radiation physicians at another hospital because, they
said, the bleeding was too severe. However, in reality, they did
not want to take responsibility for a bad outcome. After seeing
the patient, we had no hesitation in starting radiation therapy
immediately and on a Saturday. The Chinese physicians would
not let him leave their ward until the family provided written
consent, saying that the hospital was not responsible if the pa-
Health Care Delivery
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Journal of Oncology Practice Publish Ahead of Print, published on March 26,
2013 as doi:10.1200/JOP.2012.000811
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tient died on the way to our center. Two days later, after bleeding
was controlled, his hospital demanded that it take over
radiation. This is not unique. There was an patient with advanced
lung cancer whom we suspected had appendicitis but
who soon died because the Chinese surgeon would not operate
on him for fear of a bad outcome.
Consultations Versus Opinions
Patients will invariably seek opinions from a number of physicians,
often leading to patient/family confusion. The patient or
family thus become the physician. The advice of friends, friends
of friends, or physician friends, none of whom have much
knowledge of the case, commonly is more trusted and more
often heeded than that of the formally consulted physicians.
Indeed, having a physician for a friend is considered wise. After
receiving so many opinions and then ours, we are then asked to
compare and contrast ours with the others.
Studies and Tests
Commonly, only the families arrive seeking consultation,
bringing records, including, in their opinion, the important
tumor markers, along with CT, positron emission tomography
(PET)/CT, and MRI results. Under their social security,
the PET/CT scans are relatively costly, at $1,200; however,
if patients want and can afford them, physicians will order
them, warranted or not. Then follow long discussions with
patients and families concerning which findings are or are
not significant.
Lucy Lu: Patients are overtested before they come to us for
consultation, bringing CT, MRI, and PET/CT scans, often
demanded by patients of their local physicians. Rarely does a
chest evaluation start with a simple x-ray. Our Western oncologists
told me we should take an x-ray first and only later resort
to CT, MRI, and so on. So Chinese physicians are losing their
physical examination abilities by relying more and more on
scanning machines. They feel they cannot make a diagnosis
without them.
Disclosure
There is a lack of full disclosure. During the initial history
taking, important facts are deliberately left out. For example,
patients may be receiving concurrent chemotherapy or may
have had recent PET/CT scans, but they might not tell us,
perhaps from lack of trust or fear of offending their Chinese
cotherapists or because, in the past, disclosing too much may
have led to trouble.
Patients are often felt by their families to be unaware of the
diagnosis or prognosis, and we are warned not to disclose them,
although most seem to know already. Patients themselves rarely
ask for a prognosis, although family members will do so.
Hospitals are reluctant to have patients die on their premises.
Lack of hospices for dying patients is problem. Patients
who do die in hospital are removed from the ward in closed
metal cylinders.
Treatment: Who Pays and How Much?
In our center, a private enterprise, with radiation therapy, chemotherapy,
and imaging capabilities on site, costs and charges
are higher than in public hospitals. Initially surprising, in the
spirit of the new Chinese free-enterprise system, everything is
negotiable, even the complete blood count price. It is now our
policy that patients must pay before each visit and procedure,
including daily radiation treatments. Otherwise, if patients become
unhappy, they will simply not pay and walk out, never to
return. It is not at all unusual that after a lengthy discussion
concerning therapy, be it chemotherapy or irradiation, patients
will not arrive for the initial therapy appointment. When we
inquire, we are told that the patient is tired and will reschedule.
What that really means is that the patient does not plan to
return. Never are we told directly why. They just do not
reappear.
Patients have stopped radiotherapy before completion because
they feel better, and chemotherapy can be and is administered
by any physician, most often by surgeons, for the
financial rewards. Thus, some of our treatments have been
stopped midstream.
Lucy Lu: Dr Garfield says that a treatment guideline is only a
guideline, not a rule or law. Our Western oncologists use guidelines
as references when making regimen decisions, whereas
Chinese physicians usually do not even look at guidelines.
Another difference is the use of dexamethasone for reducing
edema around a spinal cord or brain lesion. In the West, dexamethasone
has been used for many years, but in China, the drug
of choice is mannitol, used sometimes even on a daily basis, for
fear of the reported adverse effects of dexamethasone. Also, use
of adriamycin seems limited in patients with lymphoma, presumably
because of excess fear of heart damage.
The difference in criteria for transfusions between our
Western oncologists and Chinese physicians is clear. The
Chinese physicians cannot give blood unless a patient’s hemoglobin
is 6.0 g, no matter the patient’s age or symptoms.
Many otherwise simple outpatient procedures performed by
Western physicians are made complicated in China. We had a
patient with ovarian cancer with severe ascites, so much so that
she could not lie down and had trouble eating. Because of our
clinic limitations at that time, we tried sending her to local
hospitals, but all refused, citing the dangers of infection, leakage,
and shock. Finally, we performed drainage with her as a
hospital outpatient; she slept well, ate well, and continued her
life without the complications about which Chinese physicians
worried, to their surprise. We are not sure they had ever performed
a paracentesis.
Another difference of treatment differences is concurrent chemotherapy
and radiation therapy for locally advanced lung cancer
in China, even though it is being done in many other East
Asian countries. We are told that Chinese patients cannot tolerate
it. Again, their main concern is adverse effects, even
though it is provides a survival advantage. In part, this is because
in China, one radiation machine will treat as many as 200
Garfifield et al
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Clinical Oncology
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Copyright © 2013 American Society of Clinical Oncology. All rights
reserved.
patients per day, so technicians do not have time for quality
control or communication with chemotherapists.
Communication and Translation
Although our nurses are fluent in English, they cannot always
accurately translate what patients or families say. Thus, we hear
nurses’ interpretations. Patients/families and nurses frequently
have long conversations, which are then translated as “the patient
says okay” or “yes” or “no.” Physician-patient conversations
are difficult to limit, control, and direct, as in the West.
However, our Western expatriot patients here are compliant,
trusting, and fully open to our therapeutic suggestions.
Lucy Lu: Usually, foreign physicians cooperate with one another
when treating the same patient. Chemotherapists share
information with radiotherapists. However, in Shanghai, physicians
hesitate to cooperate. They feel threatened and offended
when their patients’ other physicians check with them about
treatments or test details.
Diagnosis
We have seen patients whose chests CTs suggest only lung
cancer. Rather than confirming the diagnosis, they ask us, because
we are the so-called experts, if it is cancer and, if so, can
they not just have one of the “knives” (see below).
Lucy Lu: Our two Western oncologists almost always demand
that patients have a biopsy before they give treatment advice or
administer therapy. They almost never treat patients without a
definite diagnosis. However, we have seen many Chinese patients
who have been treated without biopsy confirmation.
A recent patient coughed for 2 weeks, and chest CT showed
a lung shadow. Two bronchoscopies were negative. After 2
weeks of antibiotics, the lesion got smaller. Even so, he then
underwent gamma knife treatment. Physicians in another hospital
later tried to determine the diagnosis by endobronchial
ultrasound but failed after the gamma knife treatment. So the
diagnosis remains unknown.
“Who’s in Charge Here?”
There is no culture of “the captain of the ship.” Thus, we cannot
control what other treatments patients are simultaneously receiving.
One patient presented with metastatic retro-orbital
maxillary adenoid cystic carcinoma, with proptosis and vision
loss. After our targeted therapy, there was resolution of signs
and symptoms and MRI improvement, and she spoke of a
so-called miracle. Nine months later, during another illness, she
stopped our therapy. She returned to the clinic 3 months later
with the original problems. When asked why she had stopped,
she had no answer. Additionally, for other intracranial lesions,
she was being treated by cyberknife, a heavily advertised treatment,
costly and not covered by national insurance. When
asked which lesions were treated, she was reluctant to ask because
she felt that the physician might be offended. When patients
have received prior conventional radiation therapy, they
are reluctant to obtain their records, and requests to the offices
that provided it are usually not honored, although they are
never directly denied.
Patient Cases We Are Seeing
The patient drawing area for Shanghai includes approximately
200 million people, with many patients coming to Shanghai
with complicated cases of cancer. If not satisfied with Shanghai
tertiary hospitals, they seek our opinion. These cases are often
rare, difficult, complicated, and heavily pretreated. Additionally,
even patients with common cancers present in uncommon
ways. Thus, we spend time on PubMed, looking at reviews, case
reports, or National Comprehensive Cancer Network guidelines.
Some patients have synchronous, seemingly unrelated
cancers, such as renal cell and breast cancers. This phenomenon,
although rare in the West, must always be considered here,
rather than assuming that one lesion is a metastasis from another.
Chinese physicians, however, invariably assume this situation
to represent one cancer, largely because of lack of general
oncology training. Thus, some patients with two curable cancers
are managed as having one incurable, metastatic cancer.
Chinese Oncologists
There are approximately 8,000 registered Chinese medical oncologists,
but we have yet to meet a general medical oncologist.
This means that when a problem arises outside of their subspecialty,
such as breast or lung cancer, they are unprepared. Those
with specialties in radiation, medical, and surgical oncology
invariably see one another as competitors rather than peers.
Who treats a patient with cancer depends on which specialist
sees the patient first. Surgeons and radiation oncologists administer
chemotherapy. Pulmonologists and medical oncologists
do not consider local therapy often enough. Patients with superior
vena cava obstruction, brain or spinal cord metastases,
and impending pathologic fractions merely have their chemotherapy
regimens changed. Patients with metastatic or stage IV
breast cancer are treated with two- and three-drug combinations
as if they had early-stage disease, with little consideration
given to antiestrogen therapy. Additionally, all too often, pathology
or imaging reports are only read, without subsequent
discussion with the pathologists or radiologists. The understanding
and use of general oncologic concepts seem to be
absent.
Lucy Lu: Oncology is a complicated subject, so an oncologist
should be a general physician as well. I feel that a patient with
cancer should be considered as a human being instead of
several body parts. But nowadays in Shanghai, local hospitals
are separated into different departments that treat only one
kind of disease. Physicians just treat their special diseases but
do not know what to do when a patient’s condition gets
complicated.
Patient Confidentiality and Privacy
Patient confidentiality and privacy seem nonexistent. Indeed,
when speaking with one patient, another patient or family will
listen in, interrupt, comment, and even disagree. In one large
Practicing Western Oncology in China
Copyright © 2013 by American Society of Clinical Oncology jop.ascopubs.
org 3
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HOSP & MED CTR on March 27, 2013 from 216.255.101.55
Copyright © 2013 American Society of Clinical Oncology. All rights
reserved.
hospital outpatient clinic we attend, in addition to medical
staff, the room contains three groups: a patient, never alone,
waiting to be seen; another group being seen; and a third group
previously seen. In addition, there also may be a representative
from the next group, peeking in to see how things are moving.
The commotion is indescribable.
Treatment Quality Control and Drug Costs
and Availability
One issue is the quality of radiation therapy and anticancer
drugs. Patients will usually buy the least expensive drugs (eg,
capecitabine), but the quality of drugs produced in China or
India is questionable, and there seems to be little quality assurance.
Anticancer drugs, even for patients treated in public hospitals,
are costly. Thus, many of the new monoclonal antibodies
and tyrosine kinase inhibitors, although available, are out of
reach for all but the wealthy. Other agents, including lapatinib,
amrubicin, eribulin, and everolimus, can only be obtained from
nearby countries or Hong Kong. Radiation therapy quality control,
with machines in use from early morning until late evening
treating 100 to 140 patients daily, is poor if attempted at all.
Compliance and Trust
Because there is little trust of physicians, when our therapy
proves ineffective, patients, rather than reporting this, will
transfer to another facility, not knowing or even caring that we
could try a different therapy. It is thought we have failed and
thus cannot be trusted with another attempt at disease control.
Most patients we see have far-advanced and heavily pretreated
cancers. Thus, our chance of finding an initial effective salvage
regimen is not high.
Discussion
In conclusion, this has been a challenging experience for us. It
was not possible to anticipate beforehand what to expect or how
to manage what we were about to experience, except by trial and
error. It can be done, although likely never efficiently. Respect
for and knowledge of Chinese culture and an attempt, as difficult
at that may be, not to be judgmental are required. Patience,
which the Chinese have in abundance, is also needed, as is an
awareness of the importance placed on so-called “face.” We feel
that we have introduced a different cancer care viewpoint and
have, with satisfaction, seen even our Chinese colleagues change
their approach to this all-too-common disease.
Lucy Lu: Shanghai is a city of 24 million people. With the
opening up of government policies, new medical technologies
and fantastic scanning machines have come here as wonderful
gifts from advanced science and technology. However, we are
attempting to serve a huge population with limited resources,
and the system to protect Chinese physicians remains a big
issue. If there are bad results, the physicians are guilty unless
they can prove themselves to be right. The speed of advancement
of the whole country is so fast that we may have missed
something that is important, and we need to think about it. We
need to learn more from the West than just importing these
fabulous machines.
Authors’ Disclosures of Potential Conflicts of Interest
The author(s) indicated no potential conflicts of interest.
Author Contributions
Conception and design: David H. Garfield
Manuscript writing: All authors
Final approval of manuscript: All authors
Corresponding author: David H. Garfield, MD, ProMed Cancer Centers-
Shanghai, 170 Danshui Road, Shanghai, 200020 China; e-mail:
d***********[email protected].
DOI: 10.1200/JOP.2012.000811 on March 26, 2013.
Garfifield et al
4 JOURNAL OF ONCOLOGY PRACTICE Copyright © 2013 by American Society of
Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at MONTEFIORE
HOSP & MED CTR on March 27, 2013 from 216.255.101.55
Copyright © 2013 American Society of Clinical Oncology. All rights
reserved. | d*****x
发帖数: 96 | | r******g
发帖数: 48 | 3 其实和睦家早就开始肿瘤的门诊治疗项目
但是还是外国医生来看病，没有外国training 的中国医生
那个中国护士叫lucy的简直就是胡扯，没有pet /ct /mri 你怎么诊断肿瘤，看胸片顶
毛用，没有这些你怎么评效和作放疗
不过我相信总有一天国内形势转好会有人会去做这个的 | r******g
发帖数: 48 | 4 最讨厌这些喝了点洋墨水，就都动不动说中国怎么样怎么样，中国也有好医生，外国也
有烂医生，从哪里来不重要，你是谁才重要。世界历史五千年，中国领先了几千年，落
后了两百年，只要不断努力，就会迅速赶上来的。 |
|
