Want the Best in Cancer Care? Cut Cancer Treatment CostsFriday, June 15, 2012 - 20:28
When should doctors stop prescribing chemotherapy for people with cancer who aren't responding to treatment? With health-care expenditures skyrocketing, how can cancer specialists provide the best cancer care to the greatest number of people? Is it ethical to devote hundreds of thousands of dollars to cancer treatments that might help someone live another week? A few more months?
Oncologists Thomas Smith and Bruce Hillner raise these questions – and many more – in a provocative commentary published May 26 by the New England Journal of Medicine. In their commentary, titled “Bending the Cost Curve in Cancer Care,” Smith and Hillner propose ten strategies to contain the overall cost of cancer care. Smith and HIllner frame their suggestions – which include limiting chemotherapy to three rounds in people who are not responding to it – with the truism that in a world of limited resources, we often need to make difficult choices. Yet every strategy they propose to cut costs would also improve cancer care.
Containing Cancer Costs: An Ethical Choice
Cancers are one of the most costly diseases to treat, and the cost of treating cancers is soaring, partly because cancers are being treated more aggressively than ever before. Pharmaceutical companies and makers of medical instruments devote billions of dollars to developing new therapies for treating cancers – costs that are passed on to consumers and insurance companies. According to figures cited by Smith and Hillner, direct costs for cancer care were at $104 billion in 2006 and are expected to reach $173 billion by 2020.
If you compare the cost-effectiveness of cancer treatment with other interventions – especially in the arena of primary care – the gap becomes even more apparent. A single dose of a drug used to stimulate the immune system after chemotherapy, called “hematopoietic colony-stimulating factors (CSFs) costs approximately $3500. As Smith and Hillman observe, “no randomized trial-based evidence for any of the four most common cancers… has shown that CSF-supported therapies improve overall cancer survival or quality of life” (2061). In comparison, it costs approximately $1105 for a male and $1407 for a female to receive all recommended vaccinations up to age 18. Each dollar spent on those vaccinations is estimated to save $16 in health-care costs – and inestimably reduce suffering and mortality.
The cost of cancer care, argue Smith and Hillman, need to be reduced so that care “to allow more people and advances to be covered without bankrupting the health care system.” They thus land squarely on a classic tension in medical ethics: the responsibility of the physician to the individual versus society as a whole (for a lovely, concise, and understandable overview of medical ethics, see William Ruddick’s entry on medical ethics in the Encyclopedia of Ethics, 1998).
Unfortunately, money often shifts the balance of this ethical tension. Is the physician acting responsibly by ordering a therapy that costs $100,000 and may prolong life by four months, when another person, with a highly responsive cancer, must forego treatment because she cannot afford to pay and has no insurance? What if there’s a five percent chance that one more round of chemotherapy might help that person live an additional 10 disease-free years? Does it make a difference if the person is 85 years old? What if it’s a 12-year-old girl? What if one week would allow that person to see his daughter married?
Five + Five = Ten Strategies
These are thorny issues, and Smith and Hillner suggest ten strategies to address them. All 10 of those strategies focus on reducing unnecessary and often harmful screenings and treatments – and increasing communication between doctors, other-care providers, families, and people with cancer. In other words, Smith and Hillman recommend practicing good medicine.
The first five strategies reflect changes in the way the authors would like to see oncologists treat people with cancer:
- “Target surveillance testing or imaging to situations in which a benefit has been shown.” (In other words, people who have had cancer don’t need to be screened every six months afterwards. Symptoms are a better indicator of recurrence for most cancers).
- “Limit second-line and third-line treatments for metastatic cancer to sequential monotherapies for most solid tumors.” (In other words, unless there’s a good reason to do so, don’t use expensive combination therapies, which are only slightly more effective, if at all, and carry a much greater risk of toxicity).
- “Limit chemotherapy to patients with good performance status, with an exception for highly responsive diseases.” (In other words, for most cancers and most people, only prescribe chemotherapy for people who are well enough to walk into the clinic by themselves).
- “Replace the routine use of white-cell-stimulating factors with a reduction in the chemotherapy dose in metastatic solid cancers.” (In other words, unless there’s a specific reason to do so, don’t use chemotherapy that’s strong enough to destroy white blood cells then rely on drugs that cost $3500 per injection to increase immune system function again, especially when there’s no proof those drugs improve quality of life or survival. Just give less intensive chemotherapy).
- “For patients who are not responding to three consecutive regiments, limit further chemotherapy to clinical trials.” (In other words, if three rounds of chemotherapy haven’t worked, it’s time to move on to a different approach).
Smith and Hillman address their second set of strategies directly to oncologists:
- “Oncologists need to recognize that the costs of care are driven by what [they] do and what [they] do not do.” (In other words, cancer specialists must recognize that the treatment choices they make for individual patients reverberate throughout the health-care system).
- “Both doctors and patients need to have more realistic expectations.” (In other words, oncologists need to be honest with themselves and the people they treat about what treatment can and cannot do).
- Realign compensation to value cognitive services, rather than chemotherapy, more highly. (In other words, treat the person, not the disease).
- Better integrate palliative care into usual oncology care (concurrent care). (In other words, eliminate existing silos between “curative” care [such as chemotherapy] and “palliative” care [such as hospice]. When these two teams work together, the person is less likely to feel that the oncologist is “giving up” by shifting to palliative care).
- The need for cost-effectiveness analysis and for some limits on care must be accepted. (In other words, oncologists may need to choose not to use expensive therapies that offer minimal benefits).
Care for the Person with Cancer, not the Cancer Patient
Smith and Hillman’s critique reveals a sorry truth of cancer treatment: Although many cancers can be cured, many cannot. Once cancer spreads throughout the body (called metastasis) and solid tumors are formed, even the most expensive, state-of-the-art treatments are rarely effective. Cure rate for metastatic solid tumors? Close to zero. Lung cancer survival? Average of eight months.
These ten strategies – designed to contain costs – also focus on the things most people with cancer and their families want: Honesty from their health-care providers. Better quality of life. Supportive care (nurses, a chaplain, a social worker, psychological support and counseling). The autonomy to make end-of-life decisions.
Smith and Hilllman also include one uncomfortable suggestion: “There must be some limits placed on the types and costs of care” (2063). But those limits might not always be what they seem. There’s good evidence that high-quality palliative care (i.e. care designed to control pain and make the person more comfortable overall , but not to address the cancer; hospice care is one example) can prolong both quality and length of life, especially when offered as a “both/and” option in conjunction with regular care. Indeed, placing limits on aggressive therapies and making better use of palliative care might help some people live longer and better – and cost far less.
Cancer as Metaphor
Undoubtedly, if Smith and Hillman’s suggestions make it much further than the pages of the New England Journal of Medicine, they are likely to cause a furor. After all, we want all the care we can get – especially we Americans. But some of our willingness to invest in treating cancers, even when the treatment is most likely futile – and harmful – lies in the metaphorical role cancer plays in our society. Cancer continues to capture our imagination – and our fears. As Susan Sontag pointed out in Illness as Metaphor (1978), cancer is a symbolically laden disease. Sontag argued convincingly (shortly after her own bout of cancer) that the cultural perception of cancer was based on a metaphor of repression. “She developed cancer because she never expressed her feelings.”
That metaphor about causes of cancer remains live and well today – and has been complicated by metaphors about cancer survival. Physicians, drug companies, and politicians have declared a “war on cancer.” People who succumb to the disease are said to lack will or drive; those who survive are honored as “fighers.” “He just didn’t fight hard enough.” “I knew she’d come through. She’s a fighter.”
These metaphors are important, because they affect the way everyone – physicians and layperson alike – react to cancers. The metaphors by which we understand cancer directly affect cancer treatments, drug development, development of medical devices, screening practices, and more. If we are in an all-out war against the disease, then we must devote all the resources we have to conquering it. And thus people with cancer are subjected to long, grueling, often harmful therapies that don’t do any good.
People who have cancer deserve better. Good doctors know when to stop. They know how to treat people with cancer, not cancer patients. They do not divide cancer treatment into silos of “usual” and “palliative care” but offer a little of both, all the time. They talk to people and their families about their options. They listen to people and their families and honor their beliefs, values, cultures, and ideologies. They are honest with themselves and their patients about what works and what doesn’t.
With their commentary, Smith and Hillner lay the groundwork for a crucially important national discussion about what, truly, is the best in cancer care. The bitter truth: Some cancers can be cured. Some can’t. Some cancers respond to current therapies. Some don’t. To use resources most equitably, and to truly provide better care to all people with cancer, we need to acknowledge that truth and make hard decisions about which people get what treatment when.
Ruddick, W. “Medical Ethics.” Encyclopedia of Ethics. Lawrence and Charlotte Becker, eds. 2nd edition. Garland 1998. http://www.nyu.edu/gsas/dept/philo/faculty/ruddick/papers/medethics.html.
Smith, T.J. & Hillner, B.E. Bending the cost curve in cancer care.The New England Journal of Medicine, 2011. 364; 21. 2060-65.
Sontag, Susan. Illness as Metaphor. New York: Farrar, Strauss, & Giroux. 1988. Print.
Photo by jennifrog courtesy of Flickr Creative Commons. http://www.flickr.com/photos/jennifrog/3064533283/sizes/l/in/photostream/