I had no choice. My friends asked me if I didn’t feel that somehow the illness had transformed my life into something abnormal. I always said the same thing: for someone who is ill, this is their new normality.”
In 1961, the Colombian writer Gabriel García Márquez published a short novel entitled “No one writes to the colonel”. It tells the story of a veteran officer of the Thousand Days’ War who goes to the post office every Friday for 15 years in the hope of receiving confirmation of his pension for services rendered for his country.
Medical oncology has made great progress in the last 25 years thanks to, among other things, discoveries such as the finding of small molecules directed against specific mutations such as the one occurring in the EGFR gene or the irruption of immunotherapy, which has allowed survival in metastatic non-small cell lung cancer to increase from 13 to 26 months.1
One of the problems frequently faced by medical oncologists in Spain is not being able to offer patients the best available treatment, even when it has shown overwhelming evidence, due to the slow bureaucracy of drug approval.1,2
Despite the above and the great problem that, in our opinion, it poses, we know that unfortunately many patients have greater and more serious concerns than not being able to offer them the latest available evidence.
When a newly diagnosed cancer patient sits down in our office for the first time, they are probably very scared and have gone through a more or less long process since the diagnosis, full of questions. Who knows how difficult it must have been for them and their loved ones to get to sleep in the previous days! Most of the time he is accompanied, although in some cases, like the colonel when he went to the post office every Friday, there is no one to sit next to him.
This is followed by some short questions about toxic habits, smoking, drinking, occupation, family history or information given to you before coming to the consultation. Finally, we can talk about the treatment and what we hope to achieve with its administration.
Sometimes we will prescribe treatments whose monthly cost exceeds 3000 euros, approximately 3 times the minimum wage in our country. The Spanish public health system will cover the entire cost and the patient will not have to know, unless they ask, how much the drug they are receiving costs. Surely other countries would envy this show of collective solidarity that allows, as far as possible, all cancer patients to receive the best approved treatment regardless of their social class. However, it is common knowledge among health professionals that patients with a good socio-economic status will have a better chance of survival and a better quality of life than those below the poverty line.3,4 Is there nothing we can do about this?
Lately, I remember a lot about a patient, let's call him Juan. He is a man of about 65 who works as a peddler and collecting scrap metal. He has slept many nights on the streets and some medical residents have seen him begging outside a supermarket near the hospital. Just over a year ago he was diagnosed with metastatic non-small cell lung cancer and started treatment with chemotherapy and immunotherapy to which he responded. However, after 6 cycles he stopped going to the oncology clinic and it was not until this October that his family doctor managed to locate him and insisted that he should return to the oncologic unit. We requested an imaging test to confirm that the disease had progressed and offered to start a second line of treatment, which he accepted. One month after starting treatment, he came to the clinic with obvious gait instability, and we performed an emergency brain CT scan, which revealed two large lesions in the right cerebral hemisphere.
When we informed him of the situation he only asked us if it was possible for him to be discharged in less than two hours as he had to pick up his bags from the hostel where he lived before 12 noon. We spoke with the radiotherapists and the Hospital Social Worker, and after 48h he was discharged having received the radiotherapy treatment. Alternative housing was found and home visits were arranged by the Palliative Care Unit.
It is more than likely and there is evidence that all of the above will have an impact on new patients coming to the medical oncology clinic. People with low income have poorer access to medical care and consult later, which delays diagnosis.5,6 In addition, issues such as smoking, alcohol consumption and poor diet are more frequent in this subgroup.7 Finally, as was the case with Juan, they also tend to have less social support, which has a negative impact on their quality of life.6–8
It is undeniable that medical oncologists will unfortunately see more and more patients like Juan in our practices. Hopefully, our managers will allow us to offer them highly effective treatments that are considerably more expensive than their income, but also to have access to a comprehensive assessment of their socio-economic situation and, immediately after diagnosis, to initiate the procedures that will allow all their needs to be fully met. We do not believe that it would be an exorbitant cost to incorporate these services into the health portfolio.
Family doctors as community health specialists should be equipped with the tools that enable them to delve into the primary prevention of poverty and bad habits and, once the problem has been established, in this case the diagnosis of cancer, to be the leaders of the multidisciplinary team involving oncologists, social workers, nurses, psychologists and other health professionals.
Finally, one of the questions that came to my mind during Juan's treatment was, if I could give this man a choice between a three-weekly cheque for 3000 euros, the value of his treatment, or the administration of the drug, which would he choose?
It is sad to think that there will be more and more patients like Juan, with no one to write to them and to whom if we could ask that question, unfortunately we already know the answer.
As the Spanish Nobel Prize winner Santiago Ramón y Cajal said, “diseases have two causes, the pathophysiological and the political, and it is the doctor's job to fight both”.
