The Cost of Cancer Care—Balancing Our Duties to Patients Versus Society: Are They Mutually Exclusive?

The cost of cancer care is a topic at the center of a national discourse on fiscal responsibility and resource allocation. According to the Centers for Medicare and Medicaid Services, national health expenditures as a percentage of the U.S. gross domestic product (GDP) totaled 5% in 1965, but are expected to total 20% of GDP by the middle of this decade [1]. Although spending on cancer care comprises only 5% of the overall health care budget [2], these costs continue to rise at a pace more rapid than any other area of health care [3]. National cancer expenditures are projected to increase from $125 billion in 2010 to $173 billion in 2020 [4]. As an increasing number of expensive targeted therapies are adopted as standards of care, the average cost of treating common cancers is rising rapidly, with drugs accounting for approximately 40% of the overall cost of cancer care [1]. Another area of increasing costs is the use of diagnostic imaging. Significant annual increases in imaging have occurred across all major cancer types, and imaging costs have been rising at a faster rate than average total costs of care [5]. As a sequela of these rising expenditures, patients are shouldering an increasing proportion of the health care cost burden, often placing them under significant financial stress. Treatment-related costs have been shown to significantly increase financial burden among underinsured patients [6]. As we struggle to control rising national cancer expenditures, oncology providers are forced to examine practice patterns and their contributions to the overall health care cost burden. In 2010, Dr. Howard Brody presented a challenge to the leaders of all medical subspecialties to devise “top five” lists of costly treatments or diagnostics that lack the evidence base to support common use [7]. In response, the American Board of Internal Medicine has promoted the Choosing Wisely campaign, encouraging physicians to choose tests and treatments that are grounded in a solid evidence base. The American Society for Clinical Oncology, along with many other specialty societies, responded to the challenge and identified the top five areas for change in current oncology practice (Table 1) [8]. Table 1. Choosing Wisely: Five Things Patients and Physicians Should Question [8] Although this initiative represents a substantial preliminary effort, the scope of the problem is more complex. In oncology, the real problem arises when there are not enough funds to pay for all treatments and tests supported by evidence. Even among all available evidence-based treatment options approved by the U.S. Food and Drug Administration, we may be forced to prioritize the use of expensive interventions, depriving some potential candidates of access to approved medications or procedures. Given the current climate of cost-consciousness in health care, there is a pressing need to be critical of the added value of each test or treatment in order to arrive at an equitable basis for decision-making in oncology. These issues add to the complexity of decisions that oncologists face daily at the level of the individual patient, often without a defined algorithm to guide the process. The added responsibility of considering the impact of each treatment or testing decision on the societal cost of cancer care brings up several ethical considerations. As oncologists, we find ourselves asking: is our duty to our individual patients, to society, or to both? How will we do our part to contain health care costs while honoring therapeutic contracts and professional obligations to do the best for each patient? How will the increasing pressure to curb expenditures affect the way that oncologists communicate with patients about tests and treatments?