Clinical Advances in Hematology & Oncology

September 2023 - Volume 21, Issue 9

From the Mundane to the Absurd

Richard R. Furman, MD

My family was downsizing our belongings, so I went to the Spectrum store to return a cable modem, cable box, and router that we no longer needed. I ceremoniously presented the equipment to the agent at the counter and after several minutes of scanning and flipping screens, I was informed that the equipment was registered to one Beth Pescatore, and only she could return it. I pointed out that we had been using and paying for these devices for the past 10 years, and that an employee must have failed to remove the equipment from the prior customer’s account before putting it on mine. Despite my explanation, I was informed there was nothing they could do, and I would have to continue holding on to the equipment. The customer service agent wryly mentioned that it was nice of me to be paying for someone else’s equipment for all these years . . .

Fortunately, this scenario did not result in any real harm; it required only a small additional payment to satisfy the cable gods. However unimportant such annoying red tape may seem in day-to-day life, scenarios just like this certainly play out with significant consequences every day in our medical practices. Recently, I had a patient with chronic lymphocytic leukemia (CLL) present with a recurrence of autoimmune hemolytic anemia. I knew that the patient’s response to single-agent corticosteroids was going to be poor, so I wanted to treat him with rituximab. Unfortunately, when we submitted the request for rituximab approval to his insurance, the response was that rituximab was not approved as a single agent for CLL; it could only be administered as part of fludarabine/cyclophosphamide/rituximab (FCR), bendamustine/rituximab (BR), or venetoclax/rituximab.

I arranged for a peer-to-peer discussion, initially thinking how simple it would be to convince someone not to force me to give the patient chemotherapy or venetoclax unnecessarily. Although the physician reviewer was seemingly sympathetic to my plight, he was not interested in approving the treatment regimen. So, now my patient is receiving venetoclax plus rituximab, with venetoclax’s primary effect being to occupy space in the medicine cabinet.

What has our world come to? This is meant to be screamed out in a loud, incredulous-sounding tone, by the way. I do have perspective that such a statement and tone is probably better reserved for the war in Ukraine, world hunger, and the oppression of civil rights, but for the purpose of this editorial, let’s consider this as the “low-hanging fruit.” A physician educator in our training program used to lecture the residents on how no one is smarter than an algorithm. I would always take great exception to this statement, as algorithms and textbooks cannot replicate the human element in providing care to patients. Physicians with great insight and understanding of the nature of disease, the treatments, and their impact  upon the patient are the ones who truly excel. Although the algorithm demands that rituximab be combined with one or two other agents, a physician knows that only rituximab is required.

Many more egregious examples exist. The most horrific example I have heard is the need for a CLL patient to have relapsed after FCR before receiving ibrutinib. We know that FCR carries a significant risk of myelodysplastic syndromes, acute myeloid leukemia, and bone marrow failure, and that patients who experience relapse after FCR have a markedly increased risk of developing deletion 17p, leading to a poorer response to ibrutinib.

The salient question is, what are we able to do about these situations? I am not talking about the wasted time and resources arguing with the insurance companies or the subsequent delay in delivering treatment to patients. The question is, what can we do about bureaucratic decisions that endanger the medical care of our patients? 

Recently, these issues have seemed to have fallen out of the press. I don’t think the problem is that so much else is going on, as Trump is always going to be getting indicted, North Korea has been rather quiet, and Elon Musk seems to be on vacation. The problem is that these illogical decisions have become routine and acceptable. 

As we gear up for another round of presidential primaries and general elections, I hope we might hear some discussions on the topic of health care, with a focus on bureaucratic hurdles that many patients must jump through to receive the right treatment. I promise to address these topics in future editorials as they come up, and I ask all of us to remain steadfast in our commitment to our patients. 


Richard R. Furman, MD