Lost in Translation: The Patient-Physician Relationship in the Molecular Era

As a medical student I had the opportunity to participate in AYA@USC, a research and clinical outreach program focusing on adolescent and young adult (AYA) cancer care. In addition to conducting research and attending didactic lectures ranging from psychosocial aspects of care to drug development and clinical trial design and enrollment, I was expected to interview patients about their cancer experience and to explore clinical implications of the didactic sessions. Among these patients, the experience of two young women, one at the private USC Norris Cancer Center and one at LAC+USC (Los Angeles County Hospital), stood out as exemplifying the difference between private and public cancer care. At a time when oncology is increasingly focused on the science of molecular pathways for personalized treatment of cancer patients, taking time to reflect on the patients' experiences was a revelation and a reminder of the art of patient care.

A 10-minute walk separates Norris, one of the 11 Dedicated Cancer Centers in the United States (hospitals that only provide cancer care), and LAC+USC, one of the nation's busiest public medical centers. The ground floor of Norris contains an aquarium with tropical fish, floor-to-ceiling wall fountain, and small chapel with stained glass. It is a remarkably calm hospital. By contrast, the adult oncology clinic at LAC+USC is across from the bustling ED with its perpetually overcrowded waiting room and entrance hall with stationed security guards and metal detectors. The hospital feels exciting and overwhelming at once. Cancer patients receive the same treatment protocols and drugs, and are cared for by the same physicians at the two hospitals. On paper, their outcomes should not differ significantly, but for cancer patients who return to the same place and physicians for months or years, the care environment matters. ¹

I first met with a young woman at Norris. The patient was in her late 20s when she was diagnosed with stage IV cancer and had no family history of cancer. She was receiving chemo while we spoke, sitting in an oversized brown leather recliner. Although it took her nearly two hours each way to drive to her appointments, she decided early on to stay at this cancer center because she liked her oncologist. It was her oncologist who called to relay test results and follow up on any concerns, and it was he who discussed fertility issues and genetic testing results with her as she was beginning treatment. Throughout the past two years, care decisions were discussed together, and this young woman felt cared for as an individual, as herself, not only as a cancer patient. Her oncologist had been a source of support, giving her hope in the process of her illness.

The next week I met with a patient at LAC. She had been diagnosed with stage IV cancer and underwent an emergency surgery a year prior, while in her early 30s. She had state-of-the-art testing of her tumor and was offered treatment on clinical trials. We spoke about her experience in a clinic room, she on a hard chair, me on a stool. This patient expressed confidence in the physicians treating her and appreciation for her care, but her frustrations with the public system and its impact on her cancer journey were clear. Residents and fellows rotating through the clinic would see her on different days depending on their set schedules. She said the physicians she saw were all kind, caring, and knowledgeable, but it was stressful and impersonal not knowing which doctor would be seeing her at each appointment. She had not been seen consistently enough by the same oncologist to develop a true bond, and had come to terms with her mortality on her own rather than as part of a patient-physician team. Her understanding of her illness and her care decisions were based more on her family's cancer history.

The two young women I met with did have many similarities. Like all AYA cancer patients, both have had to face illness and mortality earlier than they ever thought they would. Both have struggled with depression since their cancer diagnoses, have undergone surgeries and multiple rounds of chemotherapy, found themselves feeling isolated as the youngest by decades in cancer support groups, and wished they had more opportunities to connect with other AYA cancer patients. Their stories should not be that different, but my overall impression was that one young woman felt more truly cared for than the other, and that her cancer experience had been a little easier because of that.

With the advent of molecular targeted therapies, the field of medical oncology has revolutionized. Through targeted therapy, oncology is becoming more effective and, theoretically, more patient centered. Academic oncologists are tasked with teaching the next generation the clinical significance of identification and translation of molecular pathways in diagnosis and management of cancer patients. These changes must not come at the expense of teaching the art of practicing oncology, of building a dependable oncologist-patient relationship.

The support offered by a strong patient-oncologist relationship is especially important to our disadvantaged patients. Despite our best efforts to give them access to the same clinical trials, drugs, surgeries, and doctors, these patients are not receiving equitable care. Although the ideal continuity-based oncologist-patient relationship is hampered by the scheduling constraints of our busy public hospitals, we must take ownership of our patients and make an effort to invest in a doctor-patient relationship even if we do not expect to see them again. Despite our increasingly tailored treatments, we will not offer the best care to our cancer patients unless we invest the time and energy to discuss, to listen, to talk with, and to care for each patient as an individual. We should focus on patient-centered care with a goal of engaging all patients and their families in meaningful relationships with their physicians and larger health care teams.