The Cancer Treatment Centers of America: Cherry picked patients and survival data used to sell “integrative” oncology to the masses

I’m not a big fan of Cancer Treatment Centers of America (CTCA). That I don’t much like CTCA should come as no surprise, given that this particular hospital chain distinguishes itself from other hospital chains by advertising its full body embrace of quackery, in particular “naturopathic oncology.” At the same time as it’s advertising its “integrative cancer care.” It all sounds great on the surface, but anyone who understands exactly what “integrative medicine” is and how it basically represents the evolution of quackery will also understand that when you “integrate” quackery and pseudomedicine with real medicine you don’t make the real medicine better. You make it worse.

The other aspect of CTCA that’s always irritated me is how it advertises how its outcomes are supposedly so much better than the average cancer hospital. For instance, they advertise their breast cancer survival at 3 years as being 14% better than what is recorded in the SEER Database, and on it goes: Lung cancer 11% better at 18 months, pancreatic cancer 8% higher at 18 months, and colon cancer 11% better at 18 months. I had wondered for some time whether these statistics were valid. To me, they didn’t really pass the “smell test,” and I rather suspected something was up. Specifically, I rather suspected a strong case of confirmation bias. Thanks to a news article by Sharon Begley that appeared yesterday on Reuters, I now realize that that almost certainly is the explanation for how CTCA produces such seemingly amazing statistics. In fact, if this report is to be believed, it borders on despicable how CTCA keeps its numbers seemingly so good.

It begins with the story of a cancer patient named Vicky Hilborn, who was diagnosed with a rare cancer, and her husband Keith Hilborn, who got her to CTCA because he had seen its better survival rates touted on its website:

Hilborn had seen CTCA’s website touting survival rates better than national averages. His call secured Vicky an appointment at the for-profit, privately held company’s Philadelphia affiliate, Eastern Regional Medical Center. There, the oncologist who examined Vicky told the couple he had treated other cases of histiocytic sarcoma, the cancer of immune-system cells that she had.

“He said, ‘We’ll have you back on your feet in no time,'” Keith recalled.

Vicky’s cancer treatment was forestalled by an infection and other complications that kept her at Eastern Regional for three weeks. In July 2009, when she got back home, things changed. Despite Keith’s calls, he said, CTCA did not schedule another appointment. As his wife got sicker, Keith, a former deputy sheriff in western Pennsylvania, was reduced to begging.

The oncology information specialist “said don’t bring her here,” he recalled. “I said you don’t understand; we’re going to lose her if you don’t treat her. She told me I’d just have to accept that.”

Vicky Hilborn never got another appointment with CTCA. She died on September 6, 2009, at age 48.

The first thing I noticed here was the enormous contrast between CTCA and where I work, actually between CTCA and everywhere I’ve ever worked. Of course, being in academia I’ve never worked in anyplace other than tertiary care hospitals, and my last two jobs have been at NCI-designated comprehensive cancer centers. NCI-designated centers cannot ever behave this way. We have to take all comers with cancer, and we cannot abandon the, which is what CTCA appears to have done in the case of Mrs. Hilborn. In the case of a patient whom we can no longer treat, we provide palliative care and hospice. Begley notes that hospitals turn away patients for all sorts of reasons, including lack of insurance or underinsurance, and this, unfortunately, is true. However, what amazed me about Begley’s story is how CTCA does this. Basically, this whole story is a compelling case that CTCA tends to turn away patients who might hurt its survival numbers. It also turns out that the numbers on CTCA’s website are cherry picked and deceptive, designed to exaggerate even the apparent advantage CTCA has.

For example, if you look at the graphs provided with Begley’s story, you’ll see that rarely do they use a full five year survival rate. True, the graphs are for advanced cancers, such as lung and pancreatic cancer, for which in some cases five year survival is uncommon. However, in the case of breast cancer, a more indolent tumor in many cases, five year survival with stage IV disease isn’t uncommon; overall the five year survival for stage IV breast cancer is in the 20% range. In any case, CTCA cherry picks shorter, earlier time points, and doesn’t extend the graphs comparing its results to the SEER Database out far enough. When that is done, the differences in survival between CTCA and SEER data largely disappear for all but prostate cancer, and for breast cancer survival at CTCA is actually slightly worse. Interestingly, in this infographic, it’s pointed out that these breast cancer survival numbers beyond what CTCA published were found in a document the CTCA submitted to the State of New Hampshire as part of its application to open a hospital in the state.

Overall:

The experts were unanimous that CTCA’s patients are different from the patients the company compares them to, in a way that skews their survival data. It has relatively few elderly patients, even though cancer is a disease of the aged. It has almost none who are uninsured or covered by Medicaid – patients who tend to die sooner if they develop cancer and who are comparatively numerous in national statistics.

In all fairness, it must be pointed out that lots of hospitals play a bit fast and loose with the statistics to make themselves look as good as possible, and just because a hospital’s patient base is different from the national average is not evidence that the hospital is skimming the cream, so to speak. Just by the community such a hospital is located in, the types of demographics it attracts, and the diseases that it is known for, one hospital can have a very different patient base than another. However, what struck me about CTCA is that this sort of “differentiation” appears to be a deliberate policy:

Carolyn Holmes, a former CTCA oncology information specialist in Tulsa, Oklahoma, said she and others routinely tried to turn away people who “were the wrong demographic” because they were less likely to have an insurance policy that CTCA preferred. Holmes said she would try to “let those people down easy.”

Equally significant, CTCA includes in its outcomes data only those patients “who received treatment at CTCA for the duration of their illness” – patients who have the ability to travel to CTCA locations from the get-go, without seeking local treatment first. That means excluding, for example, those who have exhausted treatment options closer to home and arrive at a CTCA facility with advanced disease.

Accepting only selected patients and calculating survival outcomes from only some of them “is a huge bias and gives an enormous advantage to CTCA,” said biostatistician Donald Berry of MD Anderson Cancer Center in Houston.

Reading between the lines, I think it’s very obvious that CTCA appears to be doing exactly what the article describes. It appears to cherry pick the “best” patients at each stage of the process, selecting patients with the best insurance, who of course tend to be higher socioeconomic status and have access to better health care, nutrition, and the like, and then only reporting results from a subset of those patients who are similarly both still healthy enough to travel to one of CTCA’s locations right from the very beginning and who received all their treatment at CTCA. Later in the article, it’s described from former CTCA oncology information specialists, whose job it was to screen prospective patients. Basically, CTCA looks for patients with “Cadillac” insurance policies, takes very few Medicare patients, and tries very hard not to take Medicaid patients, resulting in a very skewed population.

Now, the part about Medicare is a bit tricky. In general, Medicare patients (for which the government keeps extensive data) do as well as any other patient population. However, the key point to remember here is that Medicare patients, except for those on disability, are almost by definition 65 or older. Discouraging Medicare patients is thus a built-in bias towards younger patients, and at one CTCA hospital for which data can be obtained, only 14% of patients were Medicare patients and only 4% were Medicaid patients, while in the SEER database 53% of patients were Medicare-eligible (i.e., 65 or over) and 14% were below the poverty level (i.e., likely to be either uninsured or on Medicaid). Moreover, the SEER Database has a number of factors that depress its apparent survival rates, including lumping together patients of all ages, patients with and without serious comorbidities, treated at cancer centers and community hospitals, and patients who weren’t even treated at all for cure or prolonged survival because their cancers were diagnosed too late, at a point beyond which medicine can do anything other than palliation. Moreover, if the former CTCA employees are to be believed, CTCA is quite blatant in its—shall we say?—discouraging of Medicaid and Medicare patients from coming to its hospitals:

The selection process begins when a prospective patient first contacts CTCA, by phone or web chat, and speaks to an oncology information specialist. “The first thing you do is be kind and greet them, but you’re qualifying them,” said Carolyn Holmes, the former oncology information specialist. “You ask, ‘How old are you?’ meaning, ‘Are you Medicare-age?'”

Holmes says she learned to recognize callers with “Cadillac insurance policies” and those from poor zip codes. She said she tried to redirect undesirable patients away from CTCA.

“You don’t want them,” Holmes said about Medicare patients. Medicaid? “Absolutely not.” Other former employees confirmed her account of screening patients based on their means of payment.

Again, in all fairness, many hospitals try to improve their payer mix, as Medicaid reimbursement is low and can even result in losing money. However, academic centers and NCI-designated cancer centers, at least, have a stated mission to care for all cancer patients. They can’t turn anyone away; so they usually try to improve their payer mix by attracting more patients with good insurance rather than using sophisticated strategies to turn away “undesirables.” What is striking about CTCA as reported in this article is how blatant it is about turning away those “undesirables,” even from the limited information in this article.

I can’t help but note a couple of things after reading this article. First, “integrative medicine” is clearly a marketing tool, and the embrace of integrative medicine can occur based on both ideology and profit. CTCA has quite intentionally occupied a niche caring for patients with advanced cancer using “integrative” methods in which quackery such as “naturopathic oncology” is “integrated” with conventional evidence-based treatment with surgery, radiation therapy, chemotherapy, and targeted therapy. Such patients with advanced cancer are a particular challenge, even to NCI-designated cancer centers, because we don’t have curative therapy for them. The best we can do is to prolong life, sometimes only by weeks or months, sometimes much longer, and to provide palliation. One way for a hospital to distinguish itself is to demonstrate significantly higher survival rates, which CTCA tries to do using statistically deceptive methods and comparisons of groups that are not comparable. Another is to claim to be better at palliation and to have the “human touch,” which CTCA also does, using woo such as acupuncture, naturopathy, and even homeopathy. AS I put it before, naturopathy is a Frankenstein monster, cobbled together using a lot of perfectly sound science-based treatments, including surgery, chemotherapy, and radiation with pure pseudoscience like naturopathy and traditional Chinese medicine bolted on like the head of the Frankenstein monster. CTCA has constructed and fully embraces that monster.

The next thing CTCA rather reminds me is that quackery is not, as is commonly claimed, primarily the purview of the left. I remind people of this time and time again when I point out the right wing contingent of the antivaccine movement, particularly the “health freedom movement.” The reason this observation is relevant is because the founder of CTCA is Richard J. Stevenson. I’ve mentioned him before but nothing about his politics. Basically, he founded CTCA in 1988 after his mother lost her battle with cancer, with a mission to “change the face of cancer,” because he and his family were “sorely disappointed by what they found. What were regarded as world-renowned cancer treatment facilities were singularly focused on the clinical and technical aspects of cancer treatment, ignoring the individual needs of the patient and the multi-faceted nature of the disease.” He also serves on the board of FreedomWorks, a nonprofit group that promotes low taxes and small government, including untying Medicare from Social Security in order to let people opt out of Medicare.

Finally, the way that CTCA advertises itself reminds me of how so-called “complementary and alternative medicine” (CAM) and “integrative medicine” practitioners and researchers do research and present evidence that CAM is efficacious. Instead of using good science, well-designed randomized clinical studies, and valid outcome measures compared to appropriate comparison groups, CTCA uses anecdotes, testimonials, and comparisons that consist of patients cherry picked to be treated at CTCA and then further cherry picked to have received all their care at CTCA and then comparing them to a database that they must know not to be a valid comparison. Yes, CTCA does indeed appear to select, use, and manipulate evidence the same way that CAM practitioners select, use, and manipulate evidence. I suppose this shouldn’t be surprising.

Whether CTCA is left or right, up or down, however, it really doesn’t matter. A very profitable business model can be made by combining pseudoscience with science, quackery with medicine, and wrapping it all together as being more “human” and “holistic.” Right now CTCA has that market cornered. Unfortunately, through the infiltration of quackademic medicine, medical academia seems poised to emulate something that medicine should not emulate, namely CTCA.