A cancer diagnosis is enough for patients and their families to deal without also
having to cope with bureaucracy, queues, crowded outpatient wards, overburdened
medical staff and parking problems when they need chemotherapy.
growing number of cancer cases (it is the number-one killer, as heart disease
fell to second place several years ago) and oncology departments having only
limited space, the idea of offering chemotherapy in the community at the health
funds’ expense is logical.
As expected, many hospitals are not thrilled
with the idea, as they fear competition from companies offering such care in the
community – even though only two such two private chemotherapy clinics have
opened in the past six or seven years.
The private firm behind the idea
Health (the name taken from initials of the three founders),
but it is known in Hebrew as Afek clinics (www.afek.org).
“We started by
providing dialysis to kidney- failure patients 20 years ago,” says
Amos Pines, an internal medicine specialist who is A.P.C.’s medical
director and one of its founders, in an interview with The Jerusalem Post. “The
company’s main focus is still dialysis, but around seven years ago, we decided
to provide chemotherapy to cancer patients in a community as an alternative to
going to hospital oncology departments.”
Pines, who previously worked at
Tel Aviv Sourasky Medical Center’s internal medicine department, says his
company operates 10 dialysis clinics all over the country, including Jerusalem
and Tel Aviv but also in the periphery. About 160 doctors, nurses, paramedics
and others work for the company.
“We also give Botox injections for
neurological problems – not for aesthetic treatments – when the patient has a
medical indication covered by the health funds. In Ramat Gan, we also perform
bone-density scans for diagnosing osteoporosis,” says Pines. “We don’t provide
any service that isn’t in the basket of health services. Even though we are a
private company, the cancer patient pays nothing for our treatment, as the cost
is completely covered by the health insurer.”
A.P.C. Health runs an
oncology clinic in Ramat Gan and Ashdod; the latter city has no general
hospital, even though one is now being built. Ashdod residents who need
chemotherapy thus would have to travel some distance to get it if there were no
private clinic. While A.P.C. has competition from a private company that
provides dialysis for kidney-failure patients, it remains the only one so far to
have freestanding clinics providing chemotherapy treatment in a community
Oncology patients always have the possibility of getting
treatment in a hospital oncology department, “But given the choice and informed
about A.P.C. clinics by their health funds... many prefer to go to a community
clinic,” says the A.P.C. Health medical director.
“We didn’t just open
dialysis and oncology clinics in this or that community,” he continues. “It was
the health funds who had a lacuna and asked us to provide services in the
community. We open clinics where the health funds find a need,” he explains. For
example, health funds asked the company if it was willing to open another
chemotherapy clinic in Kiryat Gat, which does not have a
“Patients are likely to think – and I understand them – that
cancer is a serious disease that needs to be treated in hospitals. They [once]
felt the same about dialysis. Today, two decades after we started, 60 percent of
dialysis patients still go to centers in hospitals three times weekly to have
the wastes filtered from their blood, while the rest go to clinics in the
community. “But it’s a matter of education for cancer patients to understand
that some treatments can be performed by highly trained medical professionals in
the community,” says Pines.
Asked whether the Health Ministry has a
pro-hospital or pro-community clinic orientation, Pines says that the ministry
does not discriminate.
“They don’t make any problems for us.
can be performed at the community level is clearly stated. A private clinic has
to meet the ministry’s standards in the level and number of medical personnel
and the available equipment. If we meet the criteria, we get
Pines notes that in the US and many other Western countries,
“chemotherapy is provided in most cases in community clinics rather than in
hospitals. Our services are actually cheaper than the official hospital rates,
but the various health funds make bulk agreements with hospitals that lower the
The A.P.C. Health’s oncology clinic in Ramat Gan treats patients
mostly in the Meuhedet and Leumit health funds, while in Ashdod, they work also
with Maccabi Health Services. As Clalit Health Services owns its own chain of
hospitals, they have little incentive to enter into agreements with A.P.C.
ONCOLOGY PATIENTS treated at the clinics list the benefits they
enjoy from not having to show up for care at a general hospital oncology
department. For many patients and their family members, just finding a paid
parking place in the hospital’s lot is a major challenge. The private clinic has
its own roomy and free parking lot. It also offers not only infusions but also
consultations with dieticians and social workers, and some complementary care,
such as reflexology, to relax patients.
The clinics offer a much more
pleasant environment, they say. The hospital is massive, with thousands of
people there ever day. One has to be careful not to catch a viral or other
infection. In the community clinic, one is not exposed to nosocomial diseases
spread in hospitals themselves, and there is privacy, with each patient in an
One of the most valued benefits is that the clinics
open at 4 p.m. and remain open until 7 or 8 p.m., several days a week, with
shorter hours on Friday. Thus neither patients nor their accompanying persons
have to miss work to come for the treatment. Most hospital oncology outpatient
facilities close before 4 p.m.
Pines says that except for the chief
physician, his oncologists work in public hospitals through the mid-afternoon
and then come to A.P.C.. Pines says that despite the general shortage of nurses
and doctors in the country, he does not have any problem finding suitable
medical personnel. They appreciate not having to work shifts late at night and
on holidays and weekends. The A.P.C. doctors are the same senior physicians who
work in hospitals, not inexperienced doctors who work only in the private
clinics, he explains, while most of the nurses work only for the company and do
Eliminating the red tape for cancer patients is probably
the biggest boon. Families that have gone through chemotherapy are familiar with
the procedures in the hospitals; undergoing tests and waiting for an oncologist
to look at the results, choose the chemo drug to be used, locate an empty bed
and find a nurse to give the infusion and then again to disconnect the tube at
the end of treatment.
But Pines states that this does not occur at his
two clinics. “The patients are sent to their health fund clinic the previous day
to undergo blood tests. We automatically receive the results, order the drugs
and prepare the chemo. Our patients are given an appointment at an exact time.
They know that they will be finished and sent home a few hours
“ONE CAN’T compare the attitude and the warm, personal relations
I have with the A.P.C. staff to the hospital,” says a health fund physician who
was herself diagnosed a few months ago with breast cancer. “At first I was
treated at a hospital, and from being a doctor, I suddenly became a patient. We
doctors don’t know how it feels to be sick. I was so discouraged and fed up that
I even contemplated stopping my chemotherapy treatments altogether.
my health fund told me about the A.P.C. clinic in Ramat Gan. I had never been
there or even heard about it. It isn’t even in my city. But when I got there I
found it was completely different than the hospital oncology department’s
outpatient services. Here, you almost don’t feel that you’re a
Unlike a hospital, where you see patients who are very weak and
debilitated, I see more pleasant things that don’t don’t remind me where I could
be a year from now. I don’t have to look for a bed or wait in long
“Having cancer is enough to struggle with; I don’t need more
challenges. I’ve been treated here for four months, and the staff all smile at
me and give me the feeling that they really care about my health instead of
being on an assembly line or feeling I am an imposition. They give me the
feeling I can overcome the disease,” she told the Post.
“Now, I recommend
it to my own health fund clinic patients.”
Eti, a woman whose 79-year-old
father is being treated for cancer at the A.P.C.. clinic in Ramat Gan, lives in
Ra’anana and brings him from Netanya to the clinic for chemo every three
“The care is so good, not only medical but the personal
relationship. I can easily park the car. As we come in the afternoon, I don’t
miss work. My father is not exposed to infectious diseases, and he is not
exposed to unpleasant sights. He enjoys having his privacy,” she
Another breast cancer patient, Eti P. of Netanya, also had been
treated in the oncology department of a hospital in the center of the country
but felt she had fallen between the cracks.
“I was so lost, having to
wait in long lines, picking up infections. My health fund, Kupat Holim Leumit,
said it would be possible for me to undergo chemotherapy at A.P.C. in Ramat
I feel as if I were home. I’m constantly hugged. There’s a different
If I don’t come one week, the secretary and the social worker
and other staffers call me at home to see if I’m all right,” Eti
ASKED TO comment on community chemotherapy services, almost all the
hospitals contacted refused to give their opinion, at least on the
Prof. Tamar Peretz, head of the Sharett Institute of Oncology at
Hadassah University Medical Center in Jerusalem’s Ein Kerem, was an exception,
and made a short and largely positive comment.
“In principle, I support
the idea of oncology services in the community as long as they are provided
properly. We at Hadassah have an oncology service in the community so that
patients do not have to visit the hospital.
We also have ambulatory
services on the Ein Kerem and Mount Scopus campuses with over 20,000 visits a
But Prof. Alberto Gabizon, chief of oncology at Jerusalem’s Shaare
Zedek Medical Center, has a more conservative view.
“Israel is a small
country with much shorter geographical distances to reach a hospital.
Ashdod, there is no hospital, so maybe cancer patients there should be able to
go for chemo to a community clinic. But I am opposed to a comprehensive switch
to community care. In most cases, this is unnecessary.
Hospitals have all
the experts on-site, the most experience and all the possible infrastructure and
equipment. Chemotherapy is possibly toxic to the patient, and sometimes there
are acute reactions. So only the hospital can cope with all eventualities,” says
the senior Jerusalem oncologist.
“A patient’s condition can suddenly
change, and a different dosage has to be given. The standard protocol may have
to be changed. Chemotherapy is a complex, dynamic treatment, so I don’t think a
private community clinic could cope with all cases,” says Gabizon. “Quality of
care is most important.”
But he conceded that hospitals should do all
they can to make ambulatory chemo treatment less of a hassle by providing more
pleasant surroundings and alleviating the parking problem for cancer
“The hospital oncology departments need not regard us as a
threat,” concludes Pines.
“While we want to share the business, we will
not take a big chunk of patients away from them. It’s a very gradual process. We
are small, with only about 15 patients per shift in Ramat Gan. Hospitals may
have have hundreds of patients a day. But our patients feel the difference."