WASHINGTON—Speakers here at the Association of American Cancer Institutes (AACI)/Cancer Center Administrators Forum Annual Meeting discussed the escalating costs of cancer care and what can be done to keep high-quality care affordable. According to a new report on the crisis in cancer care from the Institute of Medicine (OT 10/10/13), the cost of cancer care is rising much faster than that of other sectors of medicine. It is expected to rise from $125 billion in 2010 to $173 billion by 2020, a 39 percent increase. In 2004, that cost figure was $72 billion.
“What keeps me awake at night is that things are moving too fast ... precision medicine is moving too quickly, “said Lee N. Newcomer, MD, MHA, Senior Vice President of UnitedHealthcare, talking about targeted new drugs in cancer care. “There is a presumption that a ‘druggable’ target works for all cancers at all times. Where is the evidence? When the evidence is there, we [insurers] will be there as well. We're in a tough spot—right now we're moving way ahead of the evidence, and we cannot afford to do so. We tend in oncology to leap ahead of the science.”
He said that in addition to the need for more hard evidence on the effectiveness of targeted therapies, oncologists need to look carefully at the cost consequences of where cancer therapy is delivered. Citing the treatment shift from community oncologists to hospital clinics, he said, “No therapy should cost more simply because it is given in a different location.”
Asked by OT about Newcomer's comments, AACI President Michelle M. LeBeau, PhD, said, “I think he raises good points. I think we do need good clinical trials.” But LeBeau, Director of the University of Chicago Comprehensive Cancer Center, defended the role of cancer centers in delivering cutting-edge therapy, noting that the standard of care is established in these academic centers.
Brian J. Druker, MD, Director of the Knight Cancer Institute at Oregon Health and Science University, said that accelerating research is the ultimate answer to the rising costs of cancer care because it holds the promise of not only earlier detection, but also prevention.
Druker, who received AACI's Distinguished Scientist Award at the meeting and whose laboratory was instrumental in the development of imatinib for chronic myeloid leukemia (CML), said that diagnosing cancer earlier and combining targeted therapy with chemotherapy “dramatically improves outcomes.” He said, “We have to move rapidly to combination therapies and we have to collaborate,” adding, “We have a big task ahead of us—we have to identify the molecular pathogenetic mutations in all cancers.”
In an interview, Druker elaborated on his views on earlier detection and cancer prevention, both of which have the potential to bring down the costs of care. “We don't want to be treating advanced cancers; we really don't.” Looking ahead to the future of cancer care, he said he envisioned giving women at very high risk of breast cancer (because of BRCA1 or BRCA2 mutations, for example) a choice: radical prophylactic surgery to remove their breasts or a preventive, well-tolerated drug to lower their risk.
In years to come, he predicted, when people's genetic risk factors can be delineated, preventive therapies based on their cancer risk-factor profiles will be possible. Asked if preventive approaches in cardiology are a good analogy to what he envisions for oncology, Druker said yes. In cardiology, he noted, people with high blood pressure are put on hypertension-lowering drugs routinely, and those with high cholesterol are routinely prescribed cholesterol-lowering drugs such as statins.
During a panel session on the costs of cancer care, the moderator Ellen V. Sigal, PhD, Chairperson and Founder of Friends of Cancer Research, called the current landscape for cancer patients “the best of times and the worst of times.” The best, she said, is that “the science has never been better.” The worst, though, is “the dysfunction in Washington, the sequester, and the fact that there just is no money.”
Peter Bach, MD, MAPP, Director of the Center for Health Policy and Outcomes, Epidemiology and Biostatics Department at Memorial Sloan-Kettering Cancer Center, said that in such times, during which rising spending is “pushing health care to the brink,” there are specific strategies that can be used to contain costs.
As one example of such a strategy, he named alternative reimbursement methods to physicians, specifically:
- Episode-based payment, which is a bundled sum for the management of a disease episode;
- Payment based on adherence to pathways—i.e., following evidence-based guidelines; and
- Competitive acquisition of outpatient drugs and biologicals.
The current system, Bach noted, makes more expensive drugs more profitable. He agreed with Newcomer that it is much cheaper to give care in the community than in the hospital.
Scott Ramsey, MD, PhD, Member in the Cancer Prevention Program at Fred Hutchinson Cancer Research Center and Director of the Hutchinson Institute for Cancer Outcomes Research, said that bringing cancer patients into treatment cost discussions is essential during an era when what he called “the financial toxicity of cancer” is having dire effects on many of them.
“We all have a role to play in addressing this financial toxicity,” he said, noting that the American Society of Clinical Oncology does now specifically recommend that oncologists discuss treatment costs, including out–of-pocket costs, with their patients.
But, he noted, such discussions are time consuming and not easy for either physicians or patients and require a workable system to provide patients with cost figures upfront. “Cost does matter in completing treatment,” Ramsey said, citing as an example the high cost of oral oncolytics, an amount that can cause some patients to abandon their treatment.
“Most patients do not understand the cost consequences of different regimens; part of patient-centered care is helping patients with financial toxicity—perhaps we need to come up with an app to show the patient out-of-pocket costs,” he said.
It is up to oncologists to help control spiraling cancer-care costs, emphasized Louis B. Jacques, MD, Director of the Coverage & Analysis Group of the Center for Medicare and Medicaid Services. “Unfortunately desperation drives a lot of marginal care,” he said, adding: “Most of the oncologists I know give you the good stuff first.”
Jacques said he would love to see quality of life measured rigorously in cancer clinical trials, which could help to discourage and reduce the use of marginal treatments that just cause the patient more suffering. “It is possible to be in so much pain that you can't meaningfully read; I don't think that's a good quality of life,” he said. “We do think it's important to avoid adverse events; this means a lot to Medicare.”
Like Newcomer, Jacques said solid clinical-trial evidence is needed to show that targeted therapies really work. Medicare is most enthusiastic about molecular diagnostic tests if there are actual data showing that these tests lead to improved health outcomes, he said, adding that he does not think new, targeted therapies will lead to cost savings in cancer care (at least in the near term)—“I do think new targeted therapies will be additions rather than substitutions.”
During the meeting, Brian J. Druker, MD, received AACI's Distinguished Scientist Award (shown here with AACI President Michelle LeBeau, PhD), recognizing his “extraordinary scientific accomplishments and contributions to cancer research.” He led the development of imatinib, now approved for use in CML, GIST, and other cancers; and his current research focuses on learning why some patients with CML become resistant to imatinib and why others still have low levels of cancer even after successful treatment.
Also receiving awards were Rep. Lois Capps (D-CA) and Rep. Peter T. King (R-NY), given the AACI Distinguished Public Service Award, recognizing exceptional leadership in “promoting cancer research and passionate commitment to the needs of patients with cancer.” Capps is co-chair of both the House Cancer Caucus and the House Nursing Caucus (which she also founded). She introduced the Planning Actively for Cancer Treatment Act earlier this year to improve the coordination of care of Medicare beneficiaries by providing coverage for both health providers and patients to jointly develop a cancer care treatment plan to address both treatment and symptom management.
King is a member of the House Cancer Caucus, and has supported legislation to increase Medicare reimbursements for screening and diagnostic mammography, fund research centers to study the relationship between the environment and breast cancer, and require insurance companies to guarantee at least 48 hours hospital care after a mastectomy.