Louis C. Keiler, MD

Louis C. Keiler, MD, Kettering Medical Center, has been studying patient satisfaction and administering direct questionnaires to patients for over 5 years. He first became interested in the topic when completing a retrospective series in residency. At the time, he observed that patient perception of toxicity severity, CTCAE definitions and physicians observations could be disparate. The disconnect in how physicians graded treatment toxicities and how patients reacted to those same outcomes made him realize this was an area of medicine that was largely ignored.

In September 2014, at the 56th annual meeting of the American Society for Radiation Oncology (ASTRO), Dr. Keiler and researchers from Kettering Medical Center and the University of Cincinnati College of Medicine presented differences in patient satisfaction between external beam radiation therapy (EBRT) and accelerated partial breast irradiation (APBI) via HDR brachytherapy. View Poster

Among the study’s conclusions was the discovery that catheter-based APBI treated patients were significantly happier and reported less toxicity than patients in the matched whole breast EBRT cohort.

Dr. Keiler shares his comments on the importance of patient satisfaction in today’s healthcare environment.

What is the importance of patient satisfaction in today’s healthcare environment and to your practice in 2015?

Patient satisfaction has always been important to my practice. I know there is now some pressure and eagerness to move toward using patient satisfaction for different metrics, as detailed by the 2010 Affordable Care Act*. However, my motivation to work on this topic predated and is unaffected by the legislation. I’ve always seen my job as an oncologist as helping my patients get what they want, whether it be a longer life, a better life, or a less painful life. One of the first conversations I have with my patients is to identify their goals for the way they want to live their life. The most common thing they’ll say they want is quality of life above all else. They are fairly overwhelmed with having cancer and want to get back to their regular lives. This is an especially reasonable goal for early stage breast cancer patients, who can be cured and disease-free 5 years down the road. But we currently have protocols that can take over a year for treatment, and that’s a tremendous outlay of time and anxiety on the patient’s part.

What treatment options are commonly selected by your early stage breast cancer patients?

About 80 percent of our patients who are eligible for partial breast brachytherapy get partial breast brachytherapy, and about 80 percent of our women who have node negative disease who don’t get APBI have hypo-fractionated radiation.

I describe brachytherapy as getting radiation from the inside out, and go through brachytherapy versus whole breast irradiation (WBI) with patients. For those eligible patients that select brachytherapy, they have generally made that decision based on a conversation with their surgeon, and the surgeon has put in a temporary balloon, or spacer, by the time they see me. So the majority of patients have already decided in favor of APBI as opposed to WBI. It is rare for a patient to change their mind, and I do not try to “sell” one delivery system over the other.

How frequent are your own interactions with both your brachytherapy patients and whole breast patients?

I see the whole breast patients at least once a week. With brachytherapy, I see the patients at least twice a day for a slightly shorter period of time compared to whole breast. Treatment visits with partial breast patients can be more rapid fire as they occur twice daily five days in a row. They don’t really have problems develop longitudinally, and the interactions don’t need to be as long. After treatment is completed, I follow all my breast cancer survivors at the same intervals regardless of modality of treatment.

Can you comment on cosmesis and how women view their results as it relates to their satisfaction?

If I were to rate how I feel I look in any aspect of my physique, I might not give myself an 8, 9 or 10, despite the fact that I’ve had no treatments to those parts of my body that I’m reporting. I would say I am not happy with how this part of my body looks, so I am going to give it a 5.

I have women who have excellent cosmesis. You can’t tell they ever had anything done to their treated breast, but they give themselves really low scores. I imagine it’s probably because they are comparing their current cosmesis to a younger version of themselves, a societal ideal, or they may just feel that way. Likewise, I have women who have poor cosmesis but they say it looks good enough and is “perfect for me.”

One way I could have improved the study would have been rewording my question on breast cosmetic scoring to ask how much the patient felt the breast remained the same cosmetically from before diagnosis to after treatment.

What are the biggest advantages of breast brachytherapy compared to whole breast irradiation (WBI) as it relates to patient satisfaction?

I practice in a small city that includes a very large rural base. I have some patients who drive an hour or more every day for their treatment. For my breast cancer patients, the biggest advantage of 5-day brachytherapy treatment over WBI is knowing their treatment can be completed with fewer car trips. Often times they’ll drive to our center, stay here, find something to do in Dayton for the interval six hours, and then drive back.

There are some patients who are tremendously upset to be in treatment for any length of time, but others tend to experience patient satisfaction based purely on how well they feel they are treated on a day-to-day basis regardless of the length of the treatment. I think the vast majority of patients have some knowledge of what is available, especially with recent newspaper, radio and television reporting on breast cancer treatment duration. People are aware that there is not a uniform practice. Obviously if a one-week treatment is available and my patients are told they need four or six weeks of treatment, they will not be happy.

My patients don’t want to dwell on what they consider to be negative aspects of their life. Each visit is a constant reminder that she has cancer, and that is not who she wants to be.

*With the Affordable Care Act in 2010, a component of Medicare reimbursement is now tied to patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (NCAHPS) survey. This 27-question government survey is administered to patients and HCAHPS scores (pronounced “H-caps”) reflect patients’ perspectives on several aspects of care: communication with doctors and nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, overall rating of hospital and recommendation of hospital.

Dr. Louis C. Keiler, III is a Radiation Oncologist practicing at Kettering Medical Center, Kettering Health Network in Kettering, OH