Care vs. Cost: How Much Is Too Much to Treat Cancer?

"You have cancer." These dreaded words are heard by more than a million Americans each year. From that point on, doctors and patients embark on the long process of therapy, trying to decide the best course of treatment. But while oncologists are able to discuss such painful matters as prognosis with their patients, they still shy away from discussing the issue of cost. Yet cost often influences physicians' treatment recommendations, finds a recent survey published in Health Affairs magazine.For the survey, conducted by Dr. Peter Neumann, director of the Center for the Evaluation of Value and Risk in Health at the Tufts Medical Center in Boston, over 700 medical oncologists from across the nation were asked about spending. And while 84% of them said that patients' out-of-pocket spending influences treatment recommendations, only 43% of them actually discuss costs with patients on a regular basis. Also, 64% agreed that Medicare reimbursement rules limit what therapies they can offer.

These issues have become increasingly important as spending on cancer medications has risen 14% annually in recent years; costs can total tens of thousands of dollars a year for some patients. Out-of-pocket costs for cancer patients have also been increasing sharply, to 27% of their yearly income for low-income people, the study notes. It is perhaps natural that doctors can't help but keep this in mind when recommending treatments, says Dr. Neumann.

Meanwhile, many of the new expensive cancer medications don't offer significantly better outcomes than current, cheaper treatments -- often the benefit is a few weeks or months of increased life expectancy.

"A Call for Help"

Oncologists, 56% of whom feel the costs of new cancer drugs will increasingly influence their decisions over the next five years, would like to see greater government intervention in cancer care. "This can be seen as a call for help," Dr. Neumann says. Oncologists feel they are left without guidance in making the hard decisions as to whether the cost of a given treatment, to the patient and to society overall, is justified by the benefit.

Respondents wanted more government research on the comparative effectiveness of cancer drugs, and more use of cost-effectiveness data in coverage and payment decisions for cancer drugs. This is important to note in light of such recent nitiatives. They also want to see more government price controls for cancer drugs for Medicare.

But when asked who should determine whether a drug provides good value for the money, 60% of respondents said they'd prefer for physicians to maintain control, although 57% also favored nonprofit organizations.

Why Doctors Don't Tell, Why Patients Don't Ask

If cost is so important, why don't doctors discuss it more often with their patients? The study notes suggest it could be because they are uncomfortable with the subject; don't have accurate knowledge about the actual costs and insurance coverage; lack the time; or because they can't provide a solution.

As to why patients don't bring up the issue, the reason could be because they are worried how it might affect their quality of care. With doctors obviously affected by cost, would patients be right to worry? "Clinical care might be not as good" because of cost considerations, says Dr. Neumann, "but we don't know. The patient might be better off in some cases." Determining that would require a different study.

Still, while 67% of oncologists said cancer treatment should be provided regardless of cost, 58% of oncologists said patients should have access to effective cancer treatments only if the treatments are cost-effective or provide good value for money. What's "good value"? Apparently, anywhere between $50,001 and $100,000 per life-year gained, according to 49% of respondents. That's a number often referred to in similar literature, Dr. Neumann notes. However, the implicit value oncologists put on one year of life gained may be much higher; other studies found that doctors placed it at $200,000 and even $300,000, he adds.

New Strategies Are Needed

What's important to acknowledge, Dr. Neumann says, is that the survey results demonstrate that physicians need to be educated about cost-effectiveness and how to communicate with patients regarding cost. "With only 36% of oncologists discussing costs on a regular basis, it seems there are no strategies in place, no tools or resources to help physicians address this uncomfortable subject," he adds. Recently, some patient advocacy and oncologists organizations have made some progress on the matter.

Pharmaceutical companies have had to adjust as well, realizing that charging tens of thousands of dollars per year for drugs is less of an option these days. Already some companies are placing caps on spending for cancer drugs at $55,000 per patient a year, such as Genentech's Avastin, or are limiting expenses to some percentage (such as 5%) of a patient's gross income.
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