Cancer Care’s “Culture of Excess”

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You probably didn’t need an expert panel of researchers to tell you that the cost of treating cancer is spiraling out of control. But one did, and what that panel has to say is eye-opening, even when you’ve heard it all before.

Reporting in The Lancet Oncology, a team of 37 people—mostly oncologists, and a handful of patient advocates—deliver a stark set of statistics and insights about the factors conspiring to push these numbers to such wildly unsustainable levels. Here’s a brief rundown:

• About 12 million people worldwide are diagnosed with cancer ever year. This number is expected to increase to 27 million by 2030
• The cost of new cancer cases worldwide was $286 billion per year in 2009.
• Most developed countries spend 4% to 7% of their healthcare budgets on cancer.

The panel discussed these concerns at the European Multidisciplinary Cancer Congress, and an audio file of this talk is available online. That’s 51 well-spent minutes if you can spare them. In the meantime, here are some highlights from the written report (the result of a 12-month investigation and which was commissioned by The Lancet Oncology) and the Congress discussion.

First, Richard Sullivan, an oncologist at King’s College, London, and lead author of the report, explains that although the absolute numbers are alarming, it’s the rate of change that is the real concern. For example, in the U.K., the total amount spent on breast cancer has increased by about 10% every year for the past four years.

Presenting an overview of the report, Sullivan notes the main drivers of this problem to be:
• Sociodemographic: The population in developed countries is aging rapidly, and age is a major risk factor for cancer. By 2040, 25% of populations in developed countries will be over 65 years old.
• Technocultural: Huge increase in number of new technologies, not only medicine, but also surgical, imaging…
• Macroeconomics: The pricing models of healthcare systems are leading to a major increase in cost of salaries, infrastructure costs, and individual technologists.

Macroeconomics provides useful methods for understanding what is happening in cancer care:

• iCER: Incremental cost-effectiveness ratios can be used to evaluate health technologies. But clinical trials don’t have embedded socioeconomic components, which is a huge missed opportunity. Just as biomarker studies are now being integrated into clinical trials, so should economic factors.

• The “asymmetric information problem“: We don’t understand the true costs are in many of our healthcare systems. Only very few people know these costs, and generally speaking that small population does not include doctors or patients. Cost needs to be linked to outcomes in a way that is apparent to everyone.

• Currently, the range of iCERs is vast. For example, in colorectal cancer, there are new drugs costing $22K per quality-adjusted life year (QALY). For hematologic malignancies, there are new drugs that cost $48K per QALY. And there are still other drugs that cost $100K per QALY. And this cost is for medication only; biomarker analyses, imaging, and surgery can also be looked at in terms of price per QALY.

• New pricing structures are needed, and are presented in the full report. For example, one option the panel explores is performance-based pricing.

• New technologies can be used much more wisely. Robotic surgery is an incredibly expensive tool in part because it is not always used in the right way, which diminishes its efficacy and increases complications, which cost money to address. One panelist noted that the Robot could end up saving money, but only if it’s used in a better way than it is now.

• According to the panel, cancer care is a complex adaptive system.

• There is a serious issue in cancer care with the moral hazard problem. These arise when an individual or institution doesn’t take full responsibilty and, shielded from any tangible consequence, acts less carefully than they should, leaving others to clean up the mess.

As many researchers have been increasingly pointing out, there is a major problem with overuse of treatments and technologies in cancer care, and a problem with unnecessary care in which medicines are used that give no benefit during the last few weeks of a patient’s life.

From the summary of the report, provided by The Lancet Oncology:

Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies.

And, an excerpt of the report as quoted in The Huffington Post:

“Evidence shows that a substantial percentage of cancer care spending occurs in the last weeks and months of life, and that in a large percentage of cases, such care is not only futile, but contrary to the goals and preferences of many patients and families if they were adequately informed of their options.

“Therefore, empowering patients through education and shared decision making can potentially improve care and lower costs. Specifically, when patients are informed that their cancer is life threatening, but there is a treatment available, many choose to be treated irrespective of personal costs, and certainly of costs borne by their insurer.

“However, there is potential to improve care and reduce spending by empowering patients to forgo expensive and futile, or low-probability care when this matches their goals and preferences, and by empowering physicians to discuss these issues with their patients, and to recommend stopping disease-directed care when appropriate.”

And, as quoted in this news story, by FiercePharma, an important question from Richard Sullivan, the lead author of the report:

“Do we bury our heads in the sand, keep our fingers crossed, and hope that it turns out fine, or do we have difficult debates and make hard choices?”

Lastly, mention must be made of the title of the panel’s report, which is: “Delivering Affordable Care in High-Income Countries.”

Once again, that sad and disturbing title is: Delivering Affordable Care in High-Income Countries.

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