Print this Article 
Send to a Friend‘And protest, only a bubble in the molten mass, pops and sighs out, and the mass hardens’ - Robinson Jeffers, ‘Shine, perishing republic’.
Lung cancer is the most common lethal malignancy in the US, estimated to have killed more than 160,000 American citizens in 2007 alone. Although the patients most at risk can be relatively easily identified--smokers, over the age of 40--there is as yet no proven effective screening method. A major part of the reason for the high casualty rate is the frequency with which patients are diagnosed at advanced stages, when currently available treatment is modest in effectiveness. However, even patients diagnosed early have a high treatment failure rate. The reasons for this are complex, but include disease biology, significant patient co-morbidity (mostly due to the ravages of long-term tobacco use and advancing age). However, a much under-appreciated cause of treatment failure is the failure to evaluate correctly at first blush, when there is a narrow window of opportunity to correctly diagnose, stage and fashion appropriate therapy.
Caring for patients with lung cancer is rendered difficult by the disease, the frail condition of patients and the demographics of lung cancer. The high proportion of indigent and under-insured patients complicates the problem. While the annual meetings of our specialties focus on in-hospital outcomes, the contribution of access problems such as inadequate health care coverage, poverty and ignorance are often under-appreciated. Like other tobacco-related illness, lung cancer is becoming a disease of socio-economics and culture. Increasingly, we see that it is patients from lower socio-economic strata in our society who suffer from it. It is most prevalent, for example, in some of the poorest states in the Union: Alabama, Arkansas, Louisiana, Mississippi, Tennessee and the boot heel of Missouri. These states also have the highest proportions of indigent patients, higher populations of minority patients, lower levels of education, more fragile health care institutions, higher rates of tobacco use and earlier age of commencement of such use.
Memphis, the city we serve, is centrally located in this region. When the ‘irresistible forces’ of highly expensive and complicated care needs meet the ‘immoveable objects’ of poverty and lack of health care coverage, something has to give. That ‘something’ is often the quality and outcome of care that patients receive. In order to cure lung cancer, surgical intervention is often required. This is usually only available within hospitals, requires the involvement of highly trained and hard-to-come-by professionals--diagnostic and interventional radiologists, pulmonologists, thoracic surgeons, possibly also radiation oncologists and, lately medical oncologists. These specialists and their tools of trade do not come cheap.
The cost of care, access to care and the quality of care are all closely intertwined. Not only are the poor and socio-economically challenged much less likely to have access to high-volume centers where quality of care is highest, but the cost entailed in seeking care often encourages them to ignore symptoms, even advice, for as long as they can, with dire consequences for outcome. We, who are elbow-deep in caring for indigent patients with lung cancer, are often faced with the need to find ways to ‘sneak’ them into hospital in order to expedite their care, or even to be able to provide care at all. In today’s health care economic climate, even not-for-profit hospitals place barriers to entry for those with no insurance coverage. The situation for those who are ‘under-insured’ is not much better, these patients are often restricted to certain health care institutions which mostly deal with the indigent and which often do not have the infrastructure and levels of staffing needed to provide high-quality care.
One possible solution to the problem may come from the institution of multi-disciplinary teams of expert specialists, made of relevant specialists who are interested and committed to caring for patients with lung cancer. We have established such an open-access ‘thoracic multi-disciplinary clinic’ in our region, where every patient is seen concurrently by relevant specialists in one clinic, without regard to insurance coverage. Our goal is to improve access to, and the quality of, care for patients with thoracic tumors. This effort, although difficult and often frustrating, has yielded encouraging early results. However, not only do patients have to drift into the radar-screens of these teams in the first place, but even multidisciplinary teams have to contend with problems of access into the institutions where care needs to be provided. We cannot escape the albatross of the cost of care and coverage of that cost.
We believe that traditional yard-sticks such as in-hospital morbidity and mortality rates are only part of the measure of quality care. Tools need to be designed to measure the adequacy and accuracy of staging; appropriateness of treatment; timeliness of diagnosis and treatment. The true impact of absent or inadequate medical insurance coverage on all parameters of quality also need to be addressed.
The wealthiest and most powerful nation in all of human history will have to decide how she wants to treat her least fortunate ones. Will she, in the words of the great Monterrey poet Robinson Jeffers, ‘thicken into empire; while protest, only a bubble in the molten mass, pops and sighs out; and the mass hardens’? Or will she remain fluid, churning and shifting as needed to allow its components to stay afloat in a living matrix of access, hope and opportunity? The people will eventually have to decide. Sooner, or later.