From the Grace Archives | Originally Published May 27, 2011 | By Dr West 

This week, a “Sounding Board” article by Drs. Thomas Smith and Bruce Hillner was published in the New England Journal of Medicine that focused on the sensitive topic of the rapidly rising costs of cancer care. Making the point that the costs of cancer care are rising in an unsustainable way and that most new agents treating cancer are priced aggressively, typically over $5000 per month, the authors proposed five interventions that oncologists could pursue that could substantially reduce the costs of cancer care without compromising outcomes. They are as follows:

1) Reduce surveillance testing and imaging for cancer: There is no proven benefit to surveillance testing for recurrence using serum tumor markers or imaging for most cancers. The authors recognize that patients and physicians both reflexively want to detect recurrence as early as possible, but the fact is that most recurrences are detected as metastatic disease and that there is no survival benefit with detecting metastatic disease when it is a little smaller vs. a little larger. It is also noted that some physician practices are financially incentivized to do testing, and more of it.

2) Favor sequential single agent approaches over combinations: Though it depends on the cancer setting, there are many in which treatment with single agent approaches delivered serially provide the same benefit as combinations, with fewer side effects and lower costs. There are certainly evidence-based exceptions, as many chemotherapy +/- targeted therapy combinations provide a higher cure rate or extend survival beyond what single agents can achieve, or at least the evidence available only demonstrates benefits for combinations. But it has become routine to add agents in later lines of therapy primarily because it’s possible to do so, including continuing agents like Herceptin (trastuzumab), Avastin (bevacizumab), and many other extraordinarily expensive medications from one line to the next after progression, month and month and year after year. There is little to no evidence of a survival benefit, yet the costs associated with this practice are tremendous.

3) Limiting chemotherapy on the basis of performance status: Because patient performance status is very consistently associated with treatment outcomes for a wide range of cancers, and because many patients with cancer are elderly and have many other medical problems along with cancer, the authors propose that oncologists do a better job of limiting the recommendation for cancer treatment to patients who can walk into the clinic independently. An exception is suggested for people who are debilitated because of a highly responsive cancer. However, the premise is that we overtreat many patients, presumably for reasons ranging from patient and family expectations to a financial motivation to do so, while it provides no real benefit but incurs significant costs.

4) Reducing chemotherapy dose in metastatic solid cancers: The authors offer the challenge that the widespread presumption that more is better in chemotherapy treatment is not backed by evidence and is associated with routine overuse of “colony stimulating factors” to boost blood counts, but which may do little more than markedly increase the cost to deliver care. While they acknowledge that there are some cancer settings in which these agents are a key component of evidence-based care, in most treatment settings for cancer, pushing up the doses and propping up counts with growth factor support may be more reflexive and based on pressures of aggressive marketing practices than solid medical evidence that it helps patients do meaningfully better. Another potential motivation for overuse is the financial windfall they can provide to oncology practices.

5) Transition earlier to symptom-directed care when benefits of further aggressive care is minimal: It is a fair criticism that oncologists and patients are complicit in a prevalent practice of continuing with chemotherapy and targeted treatments far beyond the point where there is a meaningful potential for benefit. Many outside of oncology, and even some within it, charge that such overtreatment is financially motivated, but those immersed in the harsh reality of a cancer diagnosis, from either the patient or physician perspective, recognize that the desire to continue treatment is largely based in a desire to offer ongoing hope. Nevertheless, it is impossible to ignore that, from the perpective of broad populations, there is typically little or no survival or symptomatic benefit to later lines of treatment without evidence to support it in heavily pretreated patients. The authors propose that discontinuing such treatment not be viewed as giving up, but rather that, as a society, we need to consider a transition to management based on symptoms and quality of life provides greater benefit than we have been inclined to do.

I’ll acknowledge that while I share many of their convictions, I am among the vast majority of practicing oncologists who transgress in many of these categories (though I’ll at least say that my motivation is based on negotiating expectations rather than financial motivations).

I want to give the authors credit for broaching several difficult topics. They also acknowledge that many of the challenges to their proposals are in the form of entrenched societal pressures, such as to test more, that more treatment is better, that the latest and invariably most expensive technology and treatments are best, and that disfavoring more treatment is “giving up”. I have to imagine that many of these points are not especially welcome to patients and caregivers, since it amounts to a limitation on interventions based on a discordance between expectations and reality, but we can expect more pressure to confront this reality of socially dictated but medically inappropriate interventions more and more as the stress of limited resources forces this.

I’ll follow with my next post providing a summary of the second part of their commentary, which explores several shifts that are suggested to be keys to more effective.

• reginac says:

  May 27, 2011 at 11:36 am

  Thank you for this, Dr. West. I read part of the article but your summary is far more understandable. This is a discussion that we need to have. I look forward to your next post.

  Regina

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  kej says:

  May 27, 2011 at 12:10 pm

  Yet another comment: does it pay off ?
  Yes, it does! One goes insane being abandoned
  And if other types of reasons matter more: Last week I wrote to the local government health agent who had refused reading training to my husband until he is back at work: Exactly what do you want: an unemployed, illiterate citizen with low grade cancer care or a citizen paying 8 K $ a month in income taxes?
  The line went quiet, and today reading training was granted so my husband can go back to work before he gets fired.

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  ssflxl says:

  May 27, 2011 at 7:19 pm

  Dr. West

  Thanks for bringing up this subject. I applaud the authors for bringing up this very sensitive topic. I agree with alot of what they have said, however, there is always exceptions.
  I will use myself as example. I was started on Tarceva 150mg – cost of $5000/mo. Subsequently, I decreased the dose down to 25mg/day myself – not because my onc told me, but I titrated by side effect. As my PET scan from last week confirmed, I did just as well on 25mg dose, so now I cut the 100mg tab to 1/4 so the cost is $4500 for 4 month instead. If there are lots more people out there who really only need 25-50 mg, then imagine the amount of savings, not to mention that you take this for months or years, not just for a couple weeks. However, there will never be a study on the max effective dose – who will sponsor such study? Pharma is not interested and no oncologist will take the risk of giving their patient a lower dose.
  Then there are people who really are very incapacitated, and giving them a fourth line agent is futile. We all have to remember that chemo is really a poison – a majority of the agents we give kills off normal cells as well as cancer cells. These end stage patients are better off with hospice service.
  The Pharmaceutical industry will need to take a large portion of responsibility for the significant price increase – we will probably need to have some price control on drugs, as it is done in Canada already. Why are some drugs cheaper in Canada?? It’s the same drug from the same company!!! The problem is with our government who succumbs to the lobbying efforts of the drug industry and that will not end anytime soon.
  Our society will need to have this discussion in a mature way – not with sound bites about death panels.
  Ultimately one can always develop national guidelines, and there will always be that one or two exception.

  ssflxl