SPIKE$: A Six-Step Protocol for Delivering Bad News About the Cost of Medical Care

DOI: 10.1200/JCO.2007.15.6208 Mr S takes you aside after his wife enters the chemotherapy room. “Doctor, how much longer is this going to continue? We already sold our house, but the20%copayonour$14,000-a-monthchemotherapy bills (paclitaxel, carboplatin, trastuzamab, and pamidronate) are adding up quickly. I’m glad she’s doing OK, but do you think she’ll last another 3 months? A year? I don’t mean to sound morbid, but I need to plan.” Mrs O is a 72-year-old rural widow on a fixed income and is enrolled in Medicare without supplemental insurance. She has stopped taking her aromatase inhibitor because she reached her “donut hole” of $2,400 for all of her chronic medicines. She searched for the least expensive medication, but 30 tablets of letrozole costs $266, anastrazole costs $279, and exemestane costs $266. Should she go back to generic tamoxifen at $22 per month? (All prices are from www.drugstore.com.). Ms S is a 43-year-old single mother whose metastatic breast cancer is shrinking on sixth-line chemotherapy with fluorouracil, leucovorin, and mitomycin injections 5 days in a row, monthly. She asks if you can do something else instead, because she cannot afford the daily $35 copayment. Your practice is obligated to collect this under insurance law. The breaking of bad news is universal to medicine, and particularly commonplace in oncology. There are several accepted ways to break bad news, including the use of a common format of structured listening to what the patient knows and wants to know, giving information in understandable amounts, reacting to the news, and checking for understanding. One of the most common protocols is the SPIKES protocol: establishing an appropriate setting; checking the patient’s perception; determining the amount of information known, wanted, and to be transferred; knowing the medical facts beforehand; exploring the emotions raised during the interview; and establishing a strategy for support. Alongside clinical bad news, oncologists are increasingly confronted with giving economic bad news. The larger societal issues are well known: medical costs are inflating at a double-digit rate, which is unsustainable. Cancer drug costs to Medicare alone were $5.3 billion in 2004 and are likely much higher today. The cost of individual regimens for metastatic colon cancer has risen from a few hundred dollars to more than $30,000 per year; the added costs of bisphosphonates (up to $1,700 per dose), pegylated filgrastim ($2,700 per dose), diagnostic computed tomography scan ($2,500 per set) or positron emission tomography scan ($3,200 per scan) easily raise the cost of treatment to more than $100,000 per year per patient. Countering this bad news, there are equally important examples of medical good news about successes of new drugs, such as 2 additional months of survival with preserved quality of life using erlotinib (Tarceva [OSI Pharmaceuticals, Melville, NY], $3400 month) compared with placebo for advanced lung cancer. There is growing evidence that patients are feeling the pinch, too. Copayments for some drugs have risen to as much as 20%. For a regimen such as carboplatin, paclitaxel, and bevacizumab for advanced non–small-cell lung cancer, the copay itself could be as much as 20% of $17,000 per month. In one study, the median out-of-pocket expense for 156 women receiving breast cancer therapy was $1,455 per month, and all of these women had some form of health insurance. On a fixed income this is not manageable, and given that this study was published in 2004, the costs are, no doubt, higher today. Additionally, out-of-pocket costs tend to mirror medical expenditures, and we know of several patients in our own practice for whom these issues have become paramount. Patients have sold their homes, tapped other resources such as college funds, switched from aromatase inhibitors (about $270 per month) to tamoxifen (available for as little as $10 per month via the Internet) for breast cancer, asked if the practice can forgo the $35 to $50 copayment for each daily visit, or, too commonly, just stopped coming for treatment. In our own practice, during one short discussion, we quickly named more than a dozen patients whose finances had changed their care options. Some of these issues came to the billing manager, and some large denials from insurance companies came to individual physicians, but we are concerned that most cost issues never came to the attention of the physicians. JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y: When the Tumor Is Not the Target VOLUME 26 NUMBER 25 SEPTEMBER 1 2008