When a general practitioner suspects cancer in one of his patients, he gives him various health examinations and asks him to consult an oncologist, the doctor specialized in the treatment of cancer. Doctor specializing in cancer diseases. The word oncologist is more frequently used in France. Given the complexity of the treatments and the number of types of cancer, we distinguish between the radiation oncologist, the Onco-hematologist and the medical oncologist, specialized in chemotherapy. To treat a patient, the oncologist, the radiation oncologist, the surgeon and the specialist of the diseased organ (for example the urologist in the case of a prostate tumor) are most often called upon to collaborate.
Roles of the Oncologist in France
Among the many specialties in medicine is oncology. The doctor specialized in this field makes every effort to identify precisely the pathology of his patient and implement the appropriate treatment. The roles of the oncologist are as follows:
- Receive and listen to new patients
- Read and analyze the prescription of the general practitioner;
- Carry out the necessary analyzes
- Establish an accurate diagnosis
- Determine the most appropriate treatment
- Inform and reassure the patient
- Refer the patient to a surgeon
- Supervise radiotherapy, chemotherapy or immunotherapy
- Follow the patient and prevent or treat side effects
- Control the evolution of the disease
Becoming an Oncologist in France
All physicians must be particularly conscientious since the treatment they indicate depends on the health of the patients. The oncologist must be extremely strict because he deals with serious pathologies and his decisions can have serious consequences. If GPs treat many conditions, oncologists are dedicated to cancer, a disease whose mere statement scares the patient and those around him. The humanity of the doctor will then be essential for the patient’s morale. It is not enough to take refuge behind too technical notions that will leave the patient helpless. The doctor must indeed offer an attentive ear and show understanding in the face of the patients’ distress. Oncologists generally work in hospitals in sometimes arduous conditions. They must be resilient to deal with the difficult situations that come their way during long days of work. They cannot be too sensitive to the pressure and unhappiness of the patients they receive. The oncologist may have to announce great news as a remission and, a few moments later, explain to relatives of another patient that there is no hope of healing. The oncologist can therefore suffer an emotional lift harmful to the practice of his profession if he does not keep a certain distance.
Oncologist in France Job Evolution
After long years of studying to become oncologist in France, it is still possible to evolve professionally. At the same time, the medical specialist can engage in teaching and research in order to transfer his knowledge and study a subject that is particularly important to him. With experience, he can also aim to run a hospital service ( Geoallo Garde Dentiste ). In order to change the environment, the oncologist can also move from a public hospital to a clinic or a University Hospital Center (CHU). Finally, if oncology is a specialty of medicine, oncologists can still specialize in the attacks of certain organs (breast, colon, lung) or in a type of treatment (chemotherapy, radiotherapy), even in surgery.
Studies to become an Oncologist in France
To enter the career of oncologist in France, at least 11 years of study are required. Above all, it is advisable to obtain a scientific baccalaureate. It is then necessary to pass the first cycle of medical studies reputed for its drastic selection. Health studies all begin with a first general year at the end of which is held the competition submitted to the famous numerus clausus. After the first two years comes the time of the externship. For 4 years, the student continues his theoretical training while putting his teaching into practice in a university hospital. A new competition sanctions the externship: National Ranking Events (ECN). The success of this competition is preponderant for the pursuit of the career of the external. Indeed, it is their result that will allow them to choose their specialty. Then begins the third cycle called internship. After five years of internship in the hospital, the intern supports the doctoral thesis to obtain the State Diploma of Doctor of Medicine. He will be able to move towards the medical oncology DES or the oncology radiotherapy. Finally, it is possible to consolidate these studies by preparing the diploma of complementary specialized studies, i.e. DESC oncology.
Context to become Oncologist in France
The profession of oncologist is particularly demanding in many ways. Psychologically first, they need to face the tragedies they encounter every day. Physically then, facing the long hours of work that this profession requires. In fact, doctors in general do not count their hours. This is all the more true in public hospitals where the lack of staff sometimes leads doctors to chain work days and night guards. This job, as difficult as it is, is however extremely rewarding. It also allows to accumulate security of job and high level of salary. Oncologists can indeed count on a salary of € 8,000 per month after a few years of experience. Regarding entry into the job market, the most difficult thing is to succeed in studies since there are very selective competitions. To be able to choose one’s specialty, one must rank among the best students. The numerus clausus does not allow to fill all the positions of doctors in France, obtaining the doctorate guarantees a fast integration within a hospital.
Present State of Oncologist in France for doctors and Patients
With the rise of cancer immunotherapy and the proliferation of drug combinations, it will become unthinkable to prescribe to patients treatments on simple clinical and biological criteria. In order to combat the disease of each patient in the most appropriate manner, it must indeed be possible to characterize it precisely in order to choose the most appropriate treatment. Hence the increasingly decisive role of diagnosis, used to guide prescription throughout the disease. However, in France, in vitro diagnostic tools are the poor parents of oncology. Validated techniques are poorly paid, and those in full development, their diffusion is hampered by funding through closed envelopes.
Today, to prescribe so-called “targeted” treatments that attack the mechanisms of the cancer cell, use of tests that measure, in tumors, biomarkers – such as proteins resulting from the expression of certain genes, for example, ALK or HER2 – to find out if the patient will respond to a treatment targeting these processes. Immunotherapy, which aims to restore the action of the immune system, is also not effective in all patients. Again, to give the treatments only wisely, it is important to know the immunological status of the patient. A single biomarker (PD1 or PDL1) has been identified as relevant so far, but experts agree that it will take many more to take into account the complexity of immune response mechanisms.
Tests and Insurance/Social Security Reimbursement in France
Such tests, called “companions”, conditioning the prescription of a drug, were developed by manufacturers such as Swiss Roche or American Dako. But, in France, their reimbursement may only take place several years after the drug itself has obtained its price from the health authorities. Roche’s Herceptin, used to treat “HER2-positive” breast cancers, one of the main expense items of Health Insurance, obtained its reimbursement price in 2000. But the test required for the prescription was not reimbursed until 2009. In the meantime, the cost was borne by the health facility – unless the health care facility had developed its own test. Today, the High Authority for Health (HAS), when it assesses the therapeutic contribution of a new drug (prerequisite for pricing) mentions the companion test in appendix of its opinion on the level medical service rendered by the drug.
The evidence of the reliability of the test will be more demanding. In addition, it will be necessary to specify whether this test is for exclusive hospital use or if it can also be performed in city medicine, in which case it is covered by a payment by the Health Insurance. Another quirk is while for drugs or medical devices, it is the manufacturer who files the application for reimbursement, for companion tests it is the professionals or learned societies that alone can. In the case of tests on biopsies, it is a medical act [of pathology] that is reimbursed, not a simple product, even if the doctor uses one despite everything.
More onto oncologist tests and Insurance reimbursement in France
The price reimbursed by Health Insurance is thus a mixture of the average price offered by the manufacturer to the cancer center, and the price of the medical procedure (the study of the biopsy). A method of fixation deemed unattractive for industrialists, whereas the information delivered thanks to the product is strategic both for the patient, in terms of choice of treatment, and for the Medicare which does not finance as well as the treatments having chances of success. But companion tests measuring a single biomarker are just the beginning of the personalized diagnosis of cancer as it looms. Tomorrow, Oncologists will want to measure a series of biomarkers simultaneously. In the case of breast cancer, it is already a reality. Four “genomic signatures” measuring a series of biomarkers are available and already in common use and, pending their evaluation by the HAS, they are financed via the so-called “RIHN” envelope (referential of innovative acts outside nomenclature). But doctors are getting impatient. Of the 30,000 chemotherapy treatments prescribed each year in France to prevent the relapse of breast cancer, 25,000 would be useless. But a study conducted on more than 6,000 patients showed that the use of a signature Genomics, measuring the expression of 70 genes used as biomarkers, has reduced the chemotherapy prescription by 14%.
They assessment of the four most advanced genomic signatures has been done, but the fact remains that, faced with the influx of innovations in oncology, the French system has struggled to meet deadlines – a way for them to save money in the short term, but a short-sighted attitude too, because inappropriately treated patients are costly to the community.
Social Security and Mutual Reimbursement for Cancer related illness
The process of 100% coverage by social security (and the mutual for the rest to pay) is initiated by the attending physician. He must complete a form called “Protocol of Care”. In principle, Social Security gives its approval within one month from receipt of the request. The social security treatment of cancer care is exercised retroactively at the beginning of the illness. The entire care path is taken into account from the very beginning, even if the start date comes before the definitive diagnosis is made. Given the delays caused by the processing of the file, it is essential to keep all the evidence of costs incurred: care sheets, proof of payments, social security and mutual insurance. Once the file has received an agreement from the Social Security, claims can be made to regularize the situation. At this point, the patient will be able to update his vital card data. This will make it possible, in particular, to use the protocol of care with healthcare professionals who practice third-party payment. In a context where the patient is subjected to numerous care and treatments, this measure considerably limits the advance of expenses that he has to realize.
The framework of cancer care by Social Security
By signing the “Care Protocol”, the patient is clearly advised of the list of care and treatment concerned by 100% coverage by social security such as health transport, required for treatments or examinations. Added to this list, so-called “comfort” medications (blue vignette), considered to be part of the treatment. The same goes for hospitalization costs. For devices or prostheses refundable, everything depends on their nature. In the context of a reconstruction, the breast prostheses can be supported 100% by the social security and the mutual. Hair prostheses are subject to a flat fee. In certain special cases, a request for a prior agreement will be required. On the other hand, some expenses remain dependent. This is the case of the fixed participation of 1 euro, deducted from the refund. It applies to medical consultations, radiological examinations and biological analyzes. The medical exemption also applies for 50 centimes for paramedical acts, 50 cents for each box of reimbursed medicine and 2 euros per prescribed journey. For each of these 2 contributions, however, the annual ceiling of 50 euros cannot be exceeded. The costs that remain the responsibility of the patient therefore concern the daily hospital fee, the private room, overruns of fees charged by some doctors and all acts or services that do not fit into the protocol of care. For all these categories, it is therefore important to check with their mutual.
Being Oncologist in France like anywhere else is a tough job both mentally and physically. It is however a rewarding one for both patients and doctors at the end of the day. The latter is rewarding monetarily for the Oncologist as well as helping their patients, and rewarding for the patients as for someone who can speak to them with tact and know the steps to take in case of early cancer.