- Joined
- Nov 27, 2005
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Appealing to my Hem/Onc colleagues for some insight regarding a real case. First off, a little background...
I'm an emergency physician in Las Vegas. My grandmother is 88, and was diagnosed with CLL ~5-6 years ago. She was symptom free until 3 weeks ago when she was admitted to a hospital in FL with a hgb of 5, determined to be a result of a warm auto-immune hemolytic anemia. They tried steroids for 2 weeks and were unsuccessful, and she has required about 2 units of prbc's per week to maintain a hgb ~9. For insurance reasons, she was air-ambulanced back to Canada, where she is a resident. Prior to leaving FL, the oncologist had recommended Rituximab, and I was in favor of this decision. For some reason, once she reached Canada, they dragged their feet for a week and have continued prednisone alone, with no improvement.
Today the oncologist in Canada suddenly recommended a combination rituximab/cytoxin/fludara as well as bone marrow bx and prophylactic abx. This seems way too aggressive, so I spoke with her and requested they begin with a trial of ritux alone, before proceeding to such an aggressive regimen. Her response blew my mind... She basically told me that the canadian government will not fund this. The only options are the 3 drug regimen or a less aggressive ritux/cytoxin regimen (with a bizarre caveat that if this regimen fails, she will not be offered ritux ever again). From a purely medical perspective, I cannot understand this approach. And from a governmental approach, I don't see how this offers cost savings. Either way, I see my grandmother getting the short end of the stick here.
Since I am way out of my specialty, I appeal to you all for your expertise. What are your thoughts on this case??
I'm an emergency physician in Las Vegas. My grandmother is 88, and was diagnosed with CLL ~5-6 years ago. She was symptom free until 3 weeks ago when she was admitted to a hospital in FL with a hgb of 5, determined to be a result of a warm auto-immune hemolytic anemia. They tried steroids for 2 weeks and were unsuccessful, and she has required about 2 units of prbc's per week to maintain a hgb ~9. For insurance reasons, she was air-ambulanced back to Canada, where she is a resident. Prior to leaving FL, the oncologist had recommended Rituximab, and I was in favor of this decision. For some reason, once she reached Canada, they dragged their feet for a week and have continued prednisone alone, with no improvement.
Today the oncologist in Canada suddenly recommended a combination rituximab/cytoxin/fludara as well as bone marrow bx and prophylactic abx. This seems way too aggressive, so I spoke with her and requested they begin with a trial of ritux alone, before proceeding to such an aggressive regimen. Her response blew my mind... She basically told me that the canadian government will not fund this. The only options are the 3 drug regimen or a less aggressive ritux/cytoxin regimen (with a bizarre caveat that if this regimen fails, she will not be offered ritux ever again). From a purely medical perspective, I cannot understand this approach. And from a governmental approach, I don't see how this offers cost savings. Either way, I see my grandmother getting the short end of the stick here.
Since I am way out of my specialty, I appeal to you all for your expertise. What are your thoughts on this case??
