Affordable oncologic care: A challenging goal
Authors: Mary Kay Barton
Journal: CA A Cancer Journal for Clinicians (2014)

Health care leaders and financial analysts predict that nearly 20% of the gross domestic product of the United States will be allocated to health care spending by the year 2021, and that the rising cost of cancer care in the nation will reach $173 billion annually by 2020, up from $125 billion in 2010. As a result, efforts are underway to control costs while still delivering high-quality care. At a workshop titled “Delivering Affordable Care in the 21st Century,” sponsored by the National Cancer Policy Forum of the Institute of Medicine in Washington, DC, in October 2012, experts outlined a vision for the use of new and existing tests, therapeutics, and procedures in a rational, evidence-based, and value-based manner. Proceedings and presentations from the session were summarized in a report published last fall in the Journal of Clinical Oncology (J Clin Oncol. 2013;31:4151-4157). Attendees included bioethicists, economists, and primary care physicians, as well as medical, surgical, and radiation oncologists. Three general areas were discussed: 1) cancer screening; 2) cancer therapeutics including systemic therapy, radiotherapy, and surgery; and 3) supportive care. “This workshop helped to raise awareness about the high cost of cancer care and possible cost drivers,” says the report's lead author Ya-Chen Tina Shih, PhD, an economist and associate professor in the department of medicine at the University of Chicago in Illinois. “ [It also helped to] inform the public that the issue of affordable cancer care is a concern throughout the cancer care continuum and provided information on a number of ongoing interventions in care delivery or payment mechanisms that can potentially lower costs without compromising quality. Further, it provided background materials for the recently released [Institute of Medicine] IOM report entitled “ ‘Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,’ ” Dr. Shih says. In the report, Dr. Shih and her colleagues cover workshop discussions on cancer screening practice patterns that have shown the overuse or inappropriate use of prostate-specific antigen (PSA)-based prostate cancer screening, colonoscopy, and mammography, as well as the underuse of these tests in some populations. For example, they cite 2 large randomized controlled trials and several observational studies that found PSA testing has little impact on prostate cancer mortality while nearly doubling the number of men diagnosed with and treated for prostate cancer. Despite the clinical trials, the rate of PSA screening has only been moderately reduced, the authors note. Soaring increases predicted in the cost of cancer care have spurred health care experts to search for ways to trim the expense of tests, treatments, and procedures. Otis Brawley, MD, chief medical officer of the American Cancer Society (ACS) and a coauthor of the report, says the ACS and 5 other organizations, including the American Urological Association, recommend that men be informed of the risks and potential benefits of prostate cancer screening and be encouraged to choose whether to undergo the test. “Many physicians and patients are not aware that no reputable medical organization has outright recommended prostate cancer screening for more than a decade,” Dr. Brawley says. Similarly, the authors point out that routine breast cancer screening with mammography can lead to overdiagnosis. Although it has been shown to decrease breast cancer mortality by 20% to 30% among women aged 50 to 69 years, this benefit is not noted until 7 years after mammography. Therefore, screening women with a life expectancy of fewer than 7 years likely will not decrease their chances of dying of breast cancer. Despite this, screening remains common in women with a low life expectancy. Likewise, transvaginal ultrasound for screening for ovarian cancer and chest x-ray for lung cancer screening are not supported by scientific data, but are commonly used. Overuse of colonoscopy has been documented among the elderly, with studies showing nearly one-quarter of patients receiving a colonoscopy within 7 years from their last one without a clinical reason, despite guidelines recommending a 10-year interval between tests. However, the underuse of cancer screening tests is also disturbing. Lack of adequate screening with mammography, Papanicolaou tests, and colonoscopy has been documented in several populations, including the less educated, the uninsured, and people of lower socioeconomic status, the authors point out. Inappropriate screening tests may lead to overdiagnosis and overtreatment, which increases costs and does not benefit patients. Education is needed for providers and patients to overcome the mindset that more is always better and will decrease mortality from cancer, even in the absence of supporting data, the authors write. Equally important are educational efforts to avoid the underuse of appropriate screening to overcome disparities in care. “These issues are complicated, but it is the obligation of the ACS to try to explain the complicated when simplifying and remaining truthful is not possible,” says Dr. Brawley. While some advances in novel systemic therapeutics for cancer have great benefits, such as tyrosine kinase inhibitors in the treatment of chronic myelocytic leukemia, most confer substantially smaller, incremental benefits. Regardless of the amount of benefit they provide to the patient, these drugs are expensive, with most costing approximately $10,000 a month. Drugs are often priced higher in the United States compared with the rest of the world. One justification for this from pharmaceutical companies is that the United States cross-subsidizes the global market and maintains incentive for pharmaceutical innovation. Regulatory factors and reimbursement also contribute to the high prices. The Centers for Medicare and Medicaid Services is not allowed to negotiate prices and many laws mandate that insurers cover oncology drugs, the authors note. In addition, off-label drug use has increased. Data from the mid-2000s show that 60% to 70% of drug administrations to cancer patients are off-label. Off-label use is not inherently incorrect, as regulatory decisions can lag behind the evidence or indications may not be sought even if evidence exists for a drug's efficacy in the treatment of a particular disease. Regardless, the off-label use of high-priced cancer drugs increases the cost of care. The authors relayed concerns about the number of studies being done that are not randomized controlled trials giving high-level data. It is thought that the increase in these small studies may be due to companies pushing out data to try to amass enough evidence, although not high-level evidence, to get off-label reimbursement on drug compendia. Likewise, payment mechanisms to oncologists for intravenous drugs administered in the office can create financial incentives for particular medications. There are cases in which a newer drug is well reimbursed and money is lost on older, standard chemotherapeutic agents with no regard for efficacy or potential value because of the current system. The reimbursement system for physicians is not aligned with promoting high-value care, and patients' high expectations are likely further cost drivers. An interesting study was cited that found that the majority of patients with metastatic lung or colorectal cancer believed they were likely to be cured with chemotherapy. Communicating the true value of noncurative therapy is necessary, the authors point out. As in medical oncology, a fee-for-service payment system can create an incentive to adopt radiation and surgical technologies that are highly reimbursed, despite limited comparative evidence showing benefit, the authors report. For example, studies have shown a rapid, increased use of brachytherapy in patients with breast cancer and intensity-modulated radiotherapy in patients with prostate and breast cancers without high-level evidence demonstrating a benefit. As an example of the difficulty of changing practice patterns, a randomized study showed that lower-cost single-fraction radiotherapy was as effective for pain control as higher-priced multiple-fraction radiotherapy. Despite these data, a more recent Surveillance, Epidemiology, and End Results-Medicare data analysis showed that multiple-fraction radiotherapy remains common, even in the last month of life. Benjamin Smith, MD, associate professor in the division of radiation oncology at The University of Texas MD Anderson Cancer Center in Houston, points out that it is often hard to understand and quantify value and long-term outcomes. While it is clear that one fraction is indicated in palliative care cases for a patient at the end of life, there are other cases that are not so clear, Dr. Smith notes. “A patient came in with a painful lesion in the humerus from a prostate cancer metastasis,” says Dr. Smith. “One fraction offers the same pain control at a much lower cost, so that was the course taken. He had good pain relief, but 6 months later it expanded and there was an impending fracture requiring orthopedic surgery for stabilization. Would he have had better tumor control with more fractions, thus avoiding surgery? There is not a way to know for sure, but it illustrates that assessing value can be challenging.” Robotic surgery was discussed as an example of technology that increases cost and may or may not add value to the surgical treatment of cancer. Just as with new radiotherapies, approval of surgical devices by the US Food and Drug Administration does not require comparative clinical trials. While media attention and patient interest has been high, there are pros and cons to robotic surgery, which is estimated to add 13% to total surgery costs. Observational studies show that robotic prostatectomy surgeries overall have fewer postoperative complications than open surgery and lower rates of inpatient mortality for prostatectomy and cystectomy procedures, but were associated with more genitourinary complications than open surgery. Given the vast heterogeneity in surgical outcomes and large learning curve with robotic surgery as well as its fast uptake, robotic surgery raises concerns about quality and cost considerations, especially in low-volume hospitals, the authors write. End-of-life care is an area in which improvements can be made. Many studies have shown that patients who receive aggressive therapy near the end of life have worse quality of life. Palliative care earlier in the disease process has been shown to improve both quality and length of life. A randomized trial of patients with metastatic non-small cell lung cancer showed that instituting palliative care at diagnosis was associated with an improved quality of life and less depression. There were cost savings as these patients received less chemotherapy at the end of life and had fewer emergency room visits and hospitalizations. Although difficult to do, physicians need to deliver better communication with patients that includes truthful information regarding their prognosis, the authors write. Data show that patients and families prefer accurate prognostic information to allow informed decision-making. To summarize, the authors state that cost drivers for cancer care include the aging demographic of the United States, overuse and inappropriate use of technologies, the rising cost of innovations, public demand for non–evidence-based services, and unrealistic patient expectations. An aging population cannot be altered, but the other drivers can be addressed. The authors note that factors contributing to costs span all oncologic specialties. The American Board of Internal Medicine has a campaign called “Choosing Wisely” that addresses overuse across multiple specialties (JAMA. 2012;307:1801-1802). The American Society of Clinical Oncology has joined this effort and has published 2 top-5 lists of practices to avoid in oncology (J Clin Oncol. [published online ahead of print October 29, 2013. doi: 10.1200/JCO.2013.53.3943.] and J Clin Oncol. 2012;30:1715-1724) (Table 1). “As an economist, I believe it is human nature to act on financial incentives,” says Dr. Shih. “The workshop has provided many examples [showing] how the current fee-for-service reimbursement system could encourage overuse and lead to waste. I am not saying that we should eliminate fee-for-service payment completely, but I do think that at least some modifications will be necessary: modifications that better align incentives to provide high-value care, not just new, expensive therapies.” The authors acknowledge that patients are unique and that individualized care is important, but greater adherence to high-quality evidence would improve the quality and value of care by limiting underuse and overuse. To this end, a multipronged approach is needed: high-level evidence must be in place before strategies are adopted; end-of-life care must be more rational; communication must improve with electronic medical records that are accessible across institutions; payment reforms and coordinated care in which all providers share resources, risks, and reimbursements to help realign incentives need to occur; and patients need to be educated so their expectations are realistic and not influenced by marketing maneuvers that promote excessive or low-yield interventions. “Ultimately, what we hope to see is a health care system that allocates our limited resources efficiently,” adds Dr. Shih. “We are not saying that physicians should do less or get paid less across the board to cut down costs. What we are saying is that we should allocate resources in a way that ensures equal access to the treatments that work, but discourages treatments that offer little or no benefit.” “The whole system is not structured to reimburse value,” adds Dr. Smith. “The more complex a treatment appears, the more you generally get paid. We need to figure out how to incentivize value, not just doing more to get paid more.”