By Dr David Eedes
There has been a lot of talk over the last few years, driven mainly by more developed countries, about the issues of cost, value and sustainability in the oncology arena.
The cost differential between extremes of costs for regimens with presumed similar efficacy was massive in one US study (1). If we accept the similar efficacy, this seems to be largely driven by doctors’ perceptions and patients’ expectations. The study cites that the highest cost differential was noted in breast cancer regimens with the differentials D$71,041 for metastatic and D$63,926 for curative treatment.
Even if these figures are way out, what it is pointing to is that the costs associated with managing cancer patients are not just due to the familiar issues of expensive new drugs coming on to the market or an increase in investigations, etc. but because of the choices of treatment regimens that may not actually offer major additional benefits to the patient. In many countries, even where patients are well insured, their health insurance is not covering everything and patients are ending up out of pocket. The number of bankruptcies in the USA that are attributable to medical costs is very high, not to mention the financial hardships patients and families face.
It also means that compliance and adherence to treatment regimens suffer when patients are unable to continue on a chosen regimen and this impacts on outcomes. Clinical trials do not factor this significant side effect into their statistical analyses and this is a concerning thought.
A study done by Ramsey, published online January 25 in the Journal of Clinical Oncology showed that the mortality rates are higher in those patients who file for bankruptcy because of the cost of their treatment than their counterparts who remain financially solvent. Using SEER data and bankruptcy records in the state of Washington, the risk for death was 80% higher in cancer patients who filed for bankruptcy than in those who did not. (2; 3)
Organisations such as ASCO have recognised this problem as far back as 2007 and have set up a task team – the Task Force on the Cost of Cancer Care. (4) The aim of this is “educating oncologists about the importance of discussing costs associated with recommended treatments, empowering patients to ask questions pertaining to the anticipated costs of their treatment options, identifying the drivers of the rising costs of cancer care, and ultimately developing policy positions that will help Americans move toward more equal access to the highest-quality care at the lowest cost.”
Various models and algorithms have been designed to help guide doctors and patients in making choices, not only taking cost and efficacy into account but also looking at what is most important to patients. ASCO have produced a booklet for patients called “Managing the Cost of Cancer Care” that addresses a number of these issues and gives practical tips. http://www.cancer.net/sites/cancer.net/files/cost_of_care_booklet.pdf (6)
An interesting algorithm comes from the Memorial Sloane Kettering that uses various factors to look at the concept of value including concepts such as:
- How much do patients benefit from the treatment?
- How difficult are the treatment’s side effects?
- Is the treatment for a rare disease?
- Does the treatment address a large public health burden?
- Is the treatment using a novel or new mechanism?
- Did the treatment cost a lot to discover or develop?
They took 54 new drugs for cancer approved since 2001 (when Gleevec was approved) and their algorithm allows the patient to compare the price the company charges to a price based on value – a price called the “Abacus Price.” Everything about these drugs that might be relevant to their value is based on data used by FDA at first approval. “DrugAbacus lets you combine this information in many different ways, based on the idea that a drug’s value can be broken up into its parts”. Using this algorithm a patient, guided by the oncologist, can vary these various factors as to how important the patient rates each one. This then assigns a value and measures it against the real cost of the treatment. A patient can do a comparison of various drugs that may be used in the treatment of their disease based on what they rate as important values to them and compare the differences. This was developed to help them make choices that are meaningful to them and within their budget.
What we are seeing from all of this is that the discussion about treatment options with patients is going to require our understanding of the different costs and not just the clinical benefits associated with the various options available. Even in the insured population, if patients are treated out of protocol in the ICON setting, co-payments may apply and these can add up. The issue of annual oncology benefit limits also needs to be factored in. If we start patients on expensive regimens with marginal benefits over cheaper options and these regimens cannot be completed due to cost then we have to ask ourselves if we are really benefitting them. Treatments leading to financial strain for marginal gains may not be the best for our patients.
In certain practices in the US a financial counsellor is a central part of the MDT. These counsellors help with pre-authorisations of treatments as well as discuss the financial implications to the patient and family of the proposed treatment regime upfront. They assist them in negotiating the complexities of accessing their health insurance as well as assisting in ensuring a financially sustainable treatment plan. An interesting discovery is that it is not uncommon for patients to have the perception that a more expensive treatment would be better. I do not think this perception is limited to patients?
Financial toxicity is an increasingly important side-effect of cancer treatment, and one that patients need to be informed of upfront. This hidden side effect may outweigh any benefit we think we will achieve. The way we practice oncology will need to change if we believe we are our patients’ best advocates.
- Nadeem H, Jayakrishnan T.T, Rajeev R, Johnston et al. Cost Differential of Chemotherapy for Solid Tumors DOI: 1200/JOP.2015.006700; published online ahead of print at jop.ascopubs.org on February 9, 2016.
- Lowry F. Risk Factor for Early Death in Cancer Patients: Bankruptcy J Clin Oncol. Published online January 25, 2016. Abstract
- Ramsey,S.D. published online January 25 in the Journal of Clinical Oncology.
- American Society of Clinical Oncology Statement: A Conceptual Framework to Assess the Value of Cancer Treatment Options. Schnipper L.E, Davidson N. E, Wollins D. S, Tyne C, Blayney D. W, Blum D et al. JCO June 22, 2015 1200/JCO.2015.61.6706 July 13, 2015 http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2015.61.6706
- Memorial Sloane Kettering DrugAbacus – an interactive exploration of drug pricing http://www.drugabacus.org/
- ASCO Managing the Sot of Cancer Care http://www.cancer.net/sites/cancer.net/files/cost_of_care_booklet.pdf