Policy analysts searching for a better understanding of health-care models often compare the cancer delivery systems of Canada and the United States. The ASCO Post recently spoke with Joseph M. Connors, MD, Clinical Professor and Director of the BC Cancer Agency’s Centre for Lymphoid Cancer, Vancouver, British Columbia. Dr. Connors shed light on his personal experiences, moving from the United States to Canada, and the differences between the two countries’ cancer care systems.
Choosing Medicine
Why did you decide to become a physician?
I grew up in rural New England on Cape Cod. As a child I was impressed by our family practitioner. He was always doing interesting work and interacting with people in a way that I wanted to. Once I reached college, however, my driving interest was in biology, and I wanted to become a marine biologist. It wasn’t until college graduation approached that I decided to apply to medical school; I was fortunate to be accepted to Yale Medical School, and that very rich academic experience cemented my decision to become a physician.
Early Career
What compelled you to pursue oncology as a specialty?
I paid my medical school tuition with scholarships and college loans. At the time, the U.S. Public Health Service offered a program in which they would provide funding for my last 2 years of medical school in exchange for a promise to work within the public health service for 2 years after my residency training. I liked the idea of serving in challenged populations and I agreed.
I postponed my public health service until after completing my 4-year residency in internal medicine. The public health service gave me a choice of the Southwest or Alaska. I always thought it would be an adventure to live in Alaska, so I found a position at the Alaskan Indian Health Service. I moved to Alaska with my wife and spent a couple of years there. I still hadn’t decided what specialty I wanted to pursue, but oncology was getting higher on the list.
During my first year with the Indian Health Service I went down to Stanford to attend a weeklong course in which several of Stanford’s prominent scientists delivered lectures to internists who were interested in basic biology. It became clear that one field that was going to be at the vanguard of biologic investigations was oncology. So while I was at Stanford, I walked over to the oncology office and asked if there were any fellowships available.
As it turned out, a fellowship was available following the last year of my service in Alaska. I applied, they accepted me, and I wound up doing a 2-year oncology fellowship at Stanford. Immediately after my fellowship, I took a position at the British Columbia Cancer Agency, where I’ve been treating patients with lymphoproliferative diseases for 30 years.
Canadian System
How does the Canadian cancer care delivery system operate?
The basic idea is that one centralized agency in each Canadian province, such as British Columbia, provides cancer care to the whole population across the entire province. Canadian health care is government financed, largely with tax revenue support, so anybody with a malignancy interacts with a single agency from diagnosis through the full continuum of care.
Moreover, there is a central repository for medical records—a pooling of patient resources in one unified agency that aggregates clinical data and provides funds for subsequent clinical trials. This unified system makes it much easier to access valuable information that can be directly applied to patient care.
Relative Benefits and Limitations
Americans are engaged in an ongoing debate about the effectiveness of the U.S. health-care system. What are the benefits of the Canadian system?
There are clear-cut differences between the U.S. and Canadian delivery systems. Instead of dealing with more than 2,200 payers, as is the case with practitioners in the United States, medical care in general—and especially cancer care—is provided to patients in British Columbia by a single-payer entity. Our system dramatically increases efficiency such that we can administer the whole system based on about 2% of health-care dollars, as opposed to the more than 20% administration costs in the States.
Another benefit for me as a clinician is one fundamental principle: Everyone has access to medical care, no matter who you are. Universal access to high-quality care is not related to income, insurance, or employment status. As a clinician, this is attractive because when I see patients, I don’t question whether they can pay for a particular treatment. So it is liberating in the sense that I can simply map out what I feel is the best therapeutic strategy for my patients, knowing that any treatment with evidence-based benefit for managing the particular disease I’m treating will be covered by our universal health-care system.
And the downsides?
In the States, treatment decisions rest primarily with the treating oncologist, and as long as patients have adequate coverage or can pay out of pocket, any available treatment is on the table. That’s not the case in Canada. We don’t get to give patients treatments unless they have proven benefit, so we have an entire system devoted to examining what evidence justifies which treatments. As an oncologist treating very sick patients, that kind of oversight can be a bit frustrating.
For instance, I cannot give a drug without evidence-based proof that the drug has efficacy and works better than the less-costly alternatives in the particular disease I’m treating. So the drawback to a centralized system is that it constrains innovative behavior, is resistant to change, and is slow to introduce new approaches. The system waits for adequate evidence before moving ahead, especially if the drug or other therapy in question is costly.
The advantage of the system in the States is that innovation thrives more readily. In Canada, we’ve sacrificed some on the novel development process in order to provide universal coverage for all our people.
Naiveté, Realism, and Optimism
Any last thoughts on the state of cancer care?
Over the past several decades, oncology has been injected with a steady dose of realism. We first believed that cancer was going to yield fairly quickly to scientific investigation. That was naive, of course. As we’ve learned, cancer is a more fundamentally biologic process than most other diseases that focus on single organs or exogenous entities. It’s a big, yet understandable, disappointment to me that over the span of my 30-year career, I have not seen effective curative agents for metastatic epithelial cancer. We’ve found ways to manipulate disseminated disease, but not cure it.
But putting on my optimistic hat, I’d give my left arm to be at the beginning of my career instead of closer to its end. The next 20 years are going to be extraordinarily productive. We’ll gain insights that will lead to curative advances that are going to astound people. And I’m glad I’ll be able to see that unfold. ■
Disclosure: Dr. Connors reported no potential conflicts of interest.
