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Issues in the Economic Analysis of Therapies for Cancer Pain

Issues in the Economic Analysis of Therapies for Cancer Pain

ABSTRACT: Economic analysis of cancer pain management is hampered by the lack of systematic outcomes research. There is some consensus on the broad structures that should be in place to provide optimal care, but the relative costs and benefits of the many analgesic interventions are not known. Clinical decision making in individual cases, like the consensus itself, is guided mainly by experience and anecdote. Meaningful economic analyses based on empirical information about cost and a range of subjective and objective outcomes are needed to minimize cost without compromising care. At present, potential problems in the reimbursement system that may be increasing the cost of pain management or compromising the quality of this care can be identified, and efforts are needed to address these problems. [ONCOLOGY 9(Suppl):71-78, 1995]

Introduction

A burgeoning clinical experience has begun to define the nature
of optimal therapies for cancer pain and the outcomes that may
be anticipated when these therapies are competently administered.
Although the existing data are inadequate for a detailed economic
analysis of diverse analgesic approaches, current information
is beginning to clarify the issues and concerns that must be addressed
as such analyses are attempted.

A Paradigm for Economic Analyses

A paradigm for economic analyses of cancer pain management must
include justification for the costs of optimal care, agreement
about the elements that constitute this care, and recognition
of the link between cancer pain and the broader clinical approach
known as palliative care. This paradigm strongly supports a more
specific framework for cost analysis that has been developed by
the pain panel of the US Agency for Health Care Policy and Research
(AHCPR) [1].

Justifying the Costs of Pain Management

Numerous surveys have established that chronic pain is experienced
by 30% to 50% of cancer patients who are receiving active antineoplastic
therapy and by 75% to 90% of those with advanced disease [2,3].
The extraordinary prevalence of this problem assures that a high
aggregate cost will be incurred by the provision of optimal care
to all patients. It is useful to explore the justification for
these costs as a starting point for economic analyses of management
strategies.

There are several compelling reasons to ensure access to qualified
caregivers and a system of care that is capable of providing the
best possible therapy for cancer pain. First, the costs of unrelieved
pain are potentially very high. Pain is strongly associated with
morbid effects on mood and other aspects of quality of life [4,5].
Severe pain produces a stress response, encourages immobility,
reduces the likelihood of salutary behaviors (such as the maintenance
of good nutrition), and complicates the medical evaluation and
treatment of the neoplasm. Substantial costs may result from the
management of pain-related complications, such as deep venous
thrombosis caused by immobility, or from the need to repeat procedures
or tests that could not be performed adequately due to pain.

Hospitalizations for pain control are common and extremely expensive.
For example, an analysis of unscheduled admissions at the City
of Hope Medical Center estimated an annual cost for uncontrolled
cancer pain that exceeded $5 million [6]. A recent Canadian survey
suggested that good palliative care could lower overall costs
by reducing the frequency of hospitalization [7].

Second, the cost of optimal pain management compares very favorably
with the costs of other cancer care. Cancer treatment in the United
States is strongly oriented to expensive antineoplastic therapies,
many of which have never been shown to have more than marginal
effects on survival. There is increasing recognition of the need
to assess these therapies in terms of a broader range of potential
benefits and burdens, including cost [8]. Although comparisons
remain speculative in the absence of meaningful economic data,
it is likely that optimal pain management and other palliative
care interventions are far less expensive than many primary antineoplastic
approaches. It is difficult to justify the failure to improve
symptom control on economic grounds, given these disparities.

Third, it is a moral imperative of medicine to provide comfort,
if this is possible and consistent with the larger goals of care
[9]. Indeed, comfort and function may be the most important treatment
objectives in a disease, like cancer, that is often incurable.

Elements of Pain Management

There is good evidence that the expert administration of simple
pharmacologic approaches can provide satisfactory pain relief
to at least 70% of cancer patients [2,3,10]. These simple approaches,
which were originally promulgated by the Cancer Unit of the World
Health Organization (WHO) [3], have been endorsed by many national
organizations [11-13] and were recently refined in a consensus
document developed by the AHCPR [14]. Those patients who are unable
to attain adequate analgesia through optimal pharmacotherapy have
numerous other options, all of which are selected on the basis
of clinical experience. Although the proportion of patients who
could potentially benefit from the full array of pharmacologic
and nonpharmacologic analgesic therapies is unknown, specialists
in cancer pain generally believe it to be extremely high, probably
more than 90%.

Although conventional practice settings do not routinely achieve
success rates of 70% to 90% [15], the clinical approaches that
potentially yield these outcomes can be explored to define the
nature and costs of optimal cancer pain management. These approaches
include a comprehensive assessment, pharmacotherapy, and alternative
analgesic approaches for refractory pain (Table 1).

Assessment of Cancer Pain

The management of cancer pain relies strongly on a comprehensive
assessment. The goals of this assessment include:

1. Detailed information about pain characteristics (such as onset
and duration, course, intensity, location, and quality).

2. Elucidation of the etiology of the pain and its relationship
to the cancer.

3. Identification of the pain syndrome and development of inferences
about the pathophysiology of the pain.

4. Understanding of the impact of the pain and related symptoms
on physical and psychosocial functioning.

5. Evaluation of the extent of disease and concurrent medical,
psychological, and social disturbances.

In patients with active cancer, the pain assessment is likely
to identify an underlying structural lesion directly related to
the neoplasm. A survey of patients referred to a pain service
in a major cancer hospital noted that previously unsuspected lesions
were identified in 63% of patients who were comprehensively evaluated;
this outcome altered the known extent of disease in virtually
all patients, changed the prognosis for some, and provided an
opportunity for a primary antineoplastic therapy in approximately
15% [16].

These data underscore the potential costs of a comprehensive pain
assessment. Pain evaluation is time consuming, requires a physical
examination, and commonly leads to imaging procedures that clarify
the relationship between the neoplasm and the symptom. The costs
of this assessment cannot be eliminated and, indeed, could potentially
yield savings related to improved management of both symptoms
and the underlying disease.

The need for meaningful cost analyses in this area is illustrated
by the evaluation of back pain in patients with metastatic cancer.
In a substantial, but ill-defined, proportion of patients, a careful
clinical evaluation of this pain syndrome suggests the need for
a relatively expensive procedure, magnetic resonance imaging.
The purpose of this procedure is to diagnose or exclude one potential
cause of back pain, epidural extension of the neoplasm, which
can produce devastating neurological impairment if not treated
early. Given the dire consequences of untreated epidural disease,
clinicians must maintain a low threshold for imaging. Although
the overall cost of this imaging is undoubtedly very high, it
is likely balanced by the savings inherent in the early discovery
of epidural disease in some patients. Indeed, it may be speculated
that prevention of one case of paralysis may save the health care
system an amount sufficient to justify, on a cost basis, many
negative imaging procedures. Economic analyses of this type are
lacking and are needed to assess the cost implications of cancer
pain evaluation.

The Role of Primary Therapy

The first step in the management of cancer pain involves consideration
of primary therapy directed against the etiology of the pain.
Radiotherapy can both provide analgesia and reduce the risks associated
with morbid structural pathology, such as impending fracture or
epidural spinal disease [17]. Some patients are offered chemotherapy
specifically for analgesic purposes, and the decision to pursue
a surgical treatment is often influenced by the potential for
analgesic consequences.

The costs associated with the requirement for expert oncologic
care to optimize analgesic outcomes merge with those associated
with treatments to prolong life. Economic models that clarify
these considerations will be complex. In some situations, it may
be possible to distinguish the use of radiotherapy for curative
or life-prolonging intent from its use as a primary analgesic
modality. In other cases, this distinction will have little meaning.
Regardless, it is important to recognize that access to competent
oncologic care, particularly radiotherapy, is an element of the
costs that must be borne to optimize pain management [1].

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