The War on Cancer: Progress at What Price?

The signing of the National Cancer Act in 1971 is heralded by many as the start of the War on Cancer. Age-specific cancer rates have been steadily declining since the early 1950s in the United States. The decline can be attributed to better education about healthy lifestyle choices, such as smoking cessation and the importance of screening for and early detection of malignancies such as breast and cervical cancer, and improved treatments, especially for childhood malignancies. Intensity-modulated radiation therapy (IMRT) and minimally invasive radical prostatectomy (MIRP) are two of the newer weapons in the War on Cancer. Each success, however, comes with a cost. The nation is experiencing one of the worst recessions in memory, and federal and state governments are grappling with increasing budget deficits. Health care products and services are becoming an increasing percentage of the gross domestic product of the United States. Although health care spending growth decelerated in 2009 in the United States, it still increased 4.0% in 2009, reaching $2.5 trillion and making health care products/services 17.6% of the gross domestic product compared with 16.6% in 2008. This increase affects the competitiveness of business in the United States, given that more money is funneled into providing health care for employees rather than into improving efficiency in production and research and development. In the article that accompanies this editorial, Nguyen et al show the cost implications of rapidly adopting new technologies, namely IMRT and MIRP, in the treatment of prostate cancer. On the basis of Surveillance, Epidemiology, and End Results-Medicare–linked data, the authors report an increased use of IMRT from 28.7% in 2002 to more than 80% in 2005. During the same time period, they found an increase in the adoption and use of MIRP from 1.5% to 28.7%. The increased use of IMRT resulted in a marginal increase in cost of almost $11,000 (2008 dollars) compared with the use of three-dimensional conformal radiotherapy (3DCRT). The marginal increase in cost for MIRP was less dramatic, only $293. The authors proceeded to extrapolate the results to the US population and determined that widespread adoption of IMRT in the treatment of prostate cancer would result in an increased spending of $282 million, whereas widespread adoption of MIRP for prostate cancer treatment would result in an increase of only $4 million. The increased use of IMRT in the treatment of prostate cancer from 2002 to 2005 that was noted by the authors has most likely continued, given that IMRT is being used in the treatment of other malignancies. The Current Procedural Terminology code for the delivery of IMRT, 77418, has increased from 38th in 2004, as ranked by allowed charges, to 18th in 2008, the most recent year for which data are available on the Center for Medicare and Medicaid Services Web site. This code is the only code in the top 20 that is specifically related to cancer treatment that is not an evaluation and management code. Analyzed another way, radiation therapy accounted for 1.6%, or $1.5 billion, of payments in 2008, according to the Berenson-Eggers Type of Service codes (BETOS). The BETOS coding system was developed primarily for analyzing the growth in Medicare expenditures. The coding system covers all Healthcare Common Procedure Coding System codes and assigns a Healthcare Common Procedure Coding System code to only one BETOS code. The BETOS coding system consists of readily understood clinical categories (as opposed to statistical or financial categories) and categories that permit objective assessment. It is stable over time and is relatively immune to minor changes in technology or practice patterns. The increased use and cost of IMRT has been noted by some of the private insurance companies. These companies have recently begun to use radiation therapy specific benefit management companies to review and approve the use of IMRT before any therapy begins. Medical oncology is not immune to the same scrutiny in the use of new targeted agents. Chemotherapy accounted for 2.1%, or $1.8 billion, of Medicare payments according to the BETOS codes. Fojo and Grady reviewed recent drug approvals and clinical trials and commented on their relevance to the issue of the increasing cost of systemic therapies. They suggest some controversial standards that could serve as a starting point to address the issues of adopting new, expensive treatments into clinical practice. Other medical specialties such as (but not limited to) critical care, infectious disease, and cardiothoracic surgery are also beginning to examine the higher cost of new technologies. Some authors have argued that the rapid adoption of new technology has contributed to the increase in health care costs. IMRT has been adopted into clinical practice, much like other new technologic advances in the field of radiotherapy, because of the process by which new radiotherapy devices are approved by the US Food and Drug Administration. The majority of radiotherapy devices obtain US Food and Drug Administration approval after the filing of a 510(k) application. This process is used for devices that are either considered to have a low potential risk of harm or are substantially equivalent to legally marketed predicate devices that were marketed in interstate commerce before May 28, 1976. IMRT was approved via this process because it is essentially radiation that is delivered from a linear accelerator; thus, the proof of efficacy that must be provided for new systemic therapies was not required. This is the same process by which the field of radiotherapy adopted conventional radiotherapy instead JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L S VOLUME 29 NUMBER 12 APRIL 2