Thomas J. Smith, MD and Bruce E. Hillner, MD have written an op-ed on the rising cost of cancer in this week’s New England Journal of Medicine. Smith is a medical oncologist and palliative care specialist at Virginia Commonwealth University-Massey Cancer Center, Richmond VA. Hillner is professor and eminent university scholar in the department of internal medicine at the Virginia Commonwealth University in Richmond, Va., and associate chair of information sciences of the department of internal medicine.
It will likely not come as a surprise to anyone that the cost of cancer care is on the rise, from $104 billion in 2006 to over $173 billion in 2020. The rise in cost is driven by both the increasing cost in therapy (witness the newly approved metastatic melanoma treatment that is $120,000 for a 12-week course of therapy) and the extent of care. Efficacy of these new drugs often do not outweigh their cost-effectiveness, resulting in an increasing cost curve that is not sustainable.
Smith and Hillner suggest five ways to reduce everyday cost of care as oncologists both directly and indirectly control the majority of cancer care costs. These include choice of medicine, supportive care type, imaging frequency, and the frequency and extent of hospitalization. The authors emphasize that these suggestions will, inevitably cause “discomfort and adjustments” and bring about dissatisfaction for patients, physicians, or payers. They emphasize, however, that their suggestions are restricted to patients that have incurable solid tumors.
The authors admit that their cost-cutting suggestions will be difficult to implement. They point out, “we as a society face tough decisions . . . however, we are convinced that we can take these steps if we work together as consumers, advocates, professional societies, and payers. There really is no other way. Our intention is to encourage other specialties to do the same and flatten the cost curve so that patients can continue to get the best new therapies." The main step is to acknowledge that change is needed.
Suggestions to Change the Behavior of Medical Oncologists
Changing Targeting Surveillance Testing or Imaging
Based on American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines, there is no evidence of benefit to surveillance testing with serum tumor markers or imaging for most cancers. One exception is colon cancer, for which there is a benefit to scheduled carcinoembryonic antigen testing as well as computed tomography. The authors suggest that decreased monitoring in conjunction with counseling may reduce patient anxiety.
Utilization of Sequential Monotherapy Rather than Combination Therapy
Both ASCO and NCCN guidelines agree that, for advanced breast cancer, for example, experts recommend “sequential monotherapy . . . in the absence of rapid clinical progression, life-threatening visceral metastases, or the need for rapid symptom and/or disease control” and state that “there is no compelling evidence that combination regimens are superior to sequential single agents.” Recent meta-analysis has shown that combination therapy has a small advantage compared to single agents but at the cost of increased toxicity. The exceptions where combination therapy is better are lymphoma and second-line colon cancer.
Limiting Chemotherapy by Performance Status
Because performance status has been shown to be a consistent major, independent predictor of treatment response and survival in cancer, the authors state that the simple rule of “patients must be well enough to walk unaided into the clinic to receive chemotherapy (ie, have an Eastern Cooperative Oncology Group performance status of 3 or below, meaning that they are capable of only limited self-care and are confined to a bed or chair more than 50% of waking hours).” Exceptions for patients that have functional limitations due to other conditions should be made.
Reduction of Chemotherapy Dosage in Metastatic Solid Tumors
The doctors point out that one of the most expensive cancer drugs is actually not a treatment but the hematopoietic colony-stimulating factors (CSFs) that are given post-chemotherapy to stimulate white blood cell growth. Survival is not improved after using CSFs in two chemo-sensitive cancers, lymphoma and small-cell lung cancer. CSFs are commonly misused and reducing chemotherapy dosage may be used to avoid CSF usage and hospitalization for patients.
Symptom-Directed Care When Chemotherapy Success is Not Likely
Drs. Smith and Hillner suggest a switch to non-chemotherapy palliative care for patients with progression of disease after three consecutive regiments. They suggest that treatment beyond these three regiments should be as part of a clinical trial or a prospective registry.
Changes to Oncologists’ Attitudes and Practice
Importance of End-of-Life Discussions
The importance of this discussion comes from various studies and shows that patients who have these conversations experience less depression or anxiety, receive less aggressive end-of-life care, and rarely die in an intensive care unit or on a ventilator. It would also save our society millions of dollars.
Oncologists need to faciliate a shift from too optimistic expectations. The authors provide the example of a recent study in which most patients with lung cancer expected to live for more than 2 years even though the average length of survival is about 8 months.
Compensation for Cognitive Services
The rising salaries of US medical oncologists are rising and earning such salaries through “reimbursement for services that are designated “evaluation and management” is not sustainable. “A system in which over half the profits in oncology are from drug sales is unsustainable,” state the authors. Their suggested change in the system would be to pay all oncologists a fixed fee per unit of cognitive care and compensate the oncology practice separately for support services similar to the system used for the technical component of medical imaging. A second suggested approach is a shift to monitored care.
Better Integration of Palliative Care
Better-integrated palliative care will decrease patients’ fears of abandonment. “This topic is fraught with misunderstanding given the references to 'death panels' during the recent debate concerning health care legislation,” according to the authors. However they cite that in large, randomized trials, palliative care showed equivalent survival and better patient and family satisfaction compared with usual care.
“Improved coordination of care that lets patients choose their course while not requiring an artificial switch from usual care to hospice will be a triple win: better quality and quantity of life plus meaningful cost savings. The impact can be quick and dramatic.”
Comparative-Effectiveness and Cost-Effectiveness Analyses
According to the authors, “the national imperative is to empower a transparent, acceptable, equitable, politically independent agency for guidance in making tough choices in the public interest so that doctors do not have to make them at the bedside.” The core principle would appear to be the link between cost and the effectiveness of a cancer treatment. Being conscious of costs is necessary to sustain our healthcare system.