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Wednesday, October 10, 2012
ONLINE FIRST: Controlling Spiraling Cancer Costs Called Moral Imperative for Oncologists
 
BY PEGGY EASTMAN

 

WASHINGTON, DC -- Oncologists have a professional and moral responsibility to help control rising cancer care costs, according to speakers at a meeting here hosted by the National Cancer Policy Forum (NCPF) of the Institute of Medicine (IOM).

 

The meeting, a workshop called “Delivering Affordable Cancer Care in the 21st Century,” focused on ways to curb rising costs in cancer care while maintaining or improving quality. A summary of the speakers’ talks and panel discussions will be published, and these will contribute to an ongoing IOM consensus study, “Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population.”

 

Workshop Co-chair Patricia A. Ganz, MD, NCPF Vice-chair and Professor in the Schools of Medicine & Public Health, Division of Cancer Prevention & Control Research, at UCLA’s Jonsson Comprehensive Cancer Center, said the consensus report is expected to be ready by next summer.

 

While praising the major advances in cancer research and technology that have led to a decline in cancer deaths and a growing population of cancer survivors, speaker after speaker warned that the rising US bill for cancer treatment is unsustainable. “We’re spending about twice as much as other high-income countries on cancer care,” said Jeffrey Peppercorn, MD, MPH, Associate Professor of Medicine in Duke University’s Division of Medical Oncology, and Faculty Associate at Duke’s Trent Center for Bioethics.

 

A growing US elderly population and a high rate of obesity will result in increased incidence and added costs for cancer care, warned Peppercorn, Chair-elect of the Ethics Committee of the American Society of Clinical Oncology and a member of ASCO’s Task Force on the Cost of Cancer Care.

 

American Cancer Society Chief Medical and Scientific Officer and Executive Vice President Otis W. Brawley, MD, agreed. “The obesity epidemic is pushing up all of our health care costs,” he said.

 

And while U.S. costs for cancer care are very high now -- placing a burden on both patients and society -- they are projected to become virtually unaffordable in the next decade at the current rate of increase, said K. Robin Yabroff, PhD, MBA, an epidemiologist in the Health Services and Economics Branch of the National Cancer Institute. The country spends about $125 billion (in 2010 dollars) on cancer care now, but that figure is expected to escalate by 27 percent to a projected $158 billion somewhere around 2020, she said. 

 

She noted, though, that this projected figure could well be an underestimate, depending on such factors as population changes, incidence trends, stage distribution at diagnosis, survival trends, and changes in the use of health services.

 

Ezekiel J. Emanuel, MD, PhD, now Vice Provost for Global Initiatives, the Diane Levy and Robert Levy University Professor, and Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, said that in an era of unsustainable health care costs, “we have a responsibility to practice effective and affordable health care,” especially when it comes to innovative treatments.

 

Emanuel, a breast oncologist who is founding chair of the NIH’s Department of Bioethics, emphasized that oncologists should stop recommending and ordering medical interventions that do not: improve survival, improve quality of life, reduce side effects and reduce costs. Most physicians in practice, though, are not cost-conscious, and have no idea what is being spent for a cancer patient on, for example, imaging, chemotherapy and hospitalizations.

 

“This is not coming from nowhere,” he said of high cancer care costs, citing publicized “breakthroughs” in survival reported enthusiastically at ASCO meetings that may in reality be just a few months or even weeks, and direct-to-consumer advertising for such innovations as the da Vinci robotic surgery for prostate cancer.

 

Another speaker, Lowell E. Schnipper, MD, Chair of ASCO’s Task Force on Cancer Care Costs, said the task force produced a guideline statement which addressed: limiting anti-cancer therapy when it is likely to be useless; limiting scans for early-stage prostate and breast cancers at low risk of metastasis; limiting routine blood tests for breast cancer patients considered to be cured; and limiting use of granulocyte colony-stimulating factor (G-CSF) -- issued as ASCO’s “Top 5” list as part of the “Choosing Wisely” campaign (OT 5/10/12 and 6/25/2012).

 

“We set out with a strong recommendation that cost be factored into cancer care,” said Schnipper, Theodore and Evelyn Berenson Professor in the Department of Medicine at Harvard Medical School, Clinical Director of Beth Israel Deaconess Medical Center Cancer Center, and Chief of its Division of Hematology/Oncology.

 

“We are responsible for an array of interventions that don’t work, are very toxic, and are duplicative. We decided it was morally appropriate to address this issue.” The task force took a strong stance on doing away with cancer care that was not based on high-quality evidence, he added.

 

ASCO is now in the process of incorporating the Top 5 list into its Quality Oncology Practice Initiative (QOPI). And, he noted, the task force has a new pilot project consisting of a computerized physician advisory tool that will allow rapid and detailed evaluation of a cancer treatment regimen, including its reported toxicities.

 

U-Shaped Curve

NCI’s Yabroff noted that cancer treatment costs for most patients tend to resemble a U-shaped curve: costs are very high in the months right after diagnosis, dip down, and then rise again steeply in the months at the end of life. Many speakers at the IOM meeting emphasized that treatment costs for patients with advanced cancer at the end of life -- for whom the therapies are likely to have little value -- are a major contributor to the high cost of cancer care.

 

“The majority of patients want to know the truth about their illness,” said Jennifer Temel, MD, Associate Professor of Medicine at Harvard Medical School and Clinical Director of Thoracic Oncology at Massachusetts General Hospital Cancer Center. “But the reality is that often we don’t divulge prognostic information because we don’t want to cause harm.”

 

She added, “We have data showing that patients who know the truth are not more distressed.” Patients who are not given the facts on their prognosis are more likely to choose aggressive care at the end of life, care that is very costly, almost always useless, and likely to be highly toxic.

 

Temel suggested that oncologists have end-of-life discussions with their patients early on when appropriate, and document a patient’s code status. She also advised that advanced cancer patients watch a video of CPR, and see exactly what resuscitation entails. The graphic depiction helps many of these patients opt for palliative care, she noted.

 

Steps to Take Right Now

There are a number of steps oncologists can take right now to help contain cancer care costs, said Deborah Schrag, MD, MPH, Associate Professor of Medicine at Harvard Medical School and Deputy Associate Director of Population Sciences at Dana-Farber/Harvard Cancer  Center, including the following:

  • Oncologists who order chemotherapy should have a plan to minimize costly emergency department visits and hospital admissions for their chemotherapy patients (an after-hours telephone consultation service, for example);
  • Cancer patients should be given accurate, comprehensive information up front about their chemotherapy regimens so they will have realistic expectations about what their treatment can and cannot accomplish; consent forms should contain clear language on risks, benefits and toxicities;
  • Anti-cancer therapies should be dispensed in smaller amounts, because a patient may die before he or she can take all of the drug(s) -- and then the costly remainder (up to $10,000 a month for some drugs) will go to waste.             

Looking ahead, both Schrag and Peppercorn emphasized that it would be unwise  to spend all of the cancer care financial pie on treatments, important though they are. “We need to save some resources for basic translational science and research; this is the ultimate solution,” said Peppercorn. “Clinical trials remain the linchpin,” added Schrag. But, she noted, “We must do better at accrual.”