Oncologists Under Increasing Pressure to Address Economic Issues in Cancer Care

Roxanne Nelson

July 14, 2008

July 14, 2008 — A number of innovative cancer treatments have recently entered clinical practice — some costing as much as $100,000 per year — but it has become apparent that many of these expensive new drugs offer uncertain benefits. Some add only a few weeks of survival at a cost of tens of thousands of dollars. It is important for oncologists and other members of the cancer community to understand how economic evaluations of cancer interventions are performed and to use and critique these evaluations, according to an article that appears in the July/August issue of CA: A Cancer Journal for Clinicians.

"If the cost of cancer care continues to rise, I think oncologists are likely to be pressured by payers to consider the economic factor," coauthor Ya-Chen Tina Shih, PhD, associate professor of biostatistics at the University of Texas MD Anderson Cancer Center, in Houston, told Medscape Oncology. "This does not mean that they should always choose the least expensive drug. Rather, it means that they will be expected to include cost as 1 of the many factors in their decision-making process."

The economic impact of cancer care has increasingly been the target of scrutiny because of the large price tag attached to many of the agents that have become available during the past few years, especially the biologics. However, cost can vary dramatically, the authors point out. For example, the cost for 6 months of systemic therapy for colorectal cancer can range from less than $100 for combination fluorouracil/leucovorin administered daily for 5 days every month, to more than $50,000 for weekly treatment with cetuximab.

Because of the tremendous difference in treatment costs, it is crucial to consider the actual benefits associated with more expensive treatments. "Physicians really have to think about cost and what it will mean to the patient," said coauthor Michael Halpern, MD, PhD, senior health scientist at RTI International, Health Services and Social Policy Research, in Washington, DC.

"The bigger issue is balancing the relative cost of treatment with its benefit," he added. "Physicians need to begin having these conversations with their patients."

Communicating With Patients About Cost

Several studies have looked at whether or not oncologists discuss treatment costs with patients, and whether cost plays a role in prescribing. In 1 study (Oncologist. 2006;11:90-95), practicing medical oncologists were surveyed about their views on the cost and value of new cancer agents and whether they believed there was a point at which incremental improvements in life expectancy did not justify extra spending.

The majority of academic oncologists who participated in the survey reported that cost does not influence their clinical practice and should not limit access to "effective" care. "Although 78% of physicians would prescribe effective therapy regardless of cost, a majority did not believe that these therapies necessarily offered 'good value'," write the authors. And even though their cost-effectiveness thresholds "were significantly higher than those values previously held to be standard for clinical interventions, there was a minimum gain in life expectancy that physicians' required for costly treatment."

In a second study (J Clin Oncol. 2007;25:233-237), researchers evaluated how oncologists communicate with patients about chemotherapy treatment costs. The authors found that the majority of oncologists were knowledgeable, to varying degrees, about their patients' finances. As for discussing the costs of chemotherapy, 42% did so always or most of the time, 32% did so sometimes, and 26% did so rarely or never. However, 80% of the participating oncologists did feel that it was important to explain how treatment choice could affect a patient's finances, although nearly a third reported a high degree of discomfort discussing costs with patients.

"Mismatch between physician and patient viewpoints has the potential to result in miscommunication and suboptimally informed treatment decisions," noted the authors.

Knowledge of Economic Evaluations Needed

In the current study, the authors emphasize the need for oncologists to understand the economic evaluations used to assess the costs and benefits of cancer treatments.

"Oncologists may not be that familiar with cost and cost effectiveness," said Dr. Halpern, "And in this paper, we wanted to help them understand the different terms that are used."

There are 6 main types of economic evaluations that are currently used: cost, cost minimization, cost effectiveness, cost utility, cost benefit, and budget impact analysis. The selection of the type of economic evaluation depends primarily on the question being addressed, but can be influenced by factors such as data availability or target audience.

Drs. Halpern and Shih identified 4 reasons they believe clinicians should be familiar with and understand economic analyses and should consider cost when making decisions and presenting treatment options.

  • To ease patient burden and facilitate decision making. Most insurance plans require patients to pay a portion of the fee for medications; with the new biologic agents, this can mean tens of thousands of dollars. Although economics should not be the primary driver when choosing treatments, it must play a role in decision making, especially when effectiveness is similar but costs are very different.

  • To make assumptions, information, and decisions explicit and transparent. Although there might be disagreements about costs, benefits, and/or methodology, a clear analysis that is available to all participants will provide a practical point from which to address such disagreements.

  • To prioritize. Resources are always scarce and, on a societal level, there will never be sufficient revenues to fund every service that every person wants. Economic analyses can help establish appropriate uses of available resources for all individuals, regardless of financial status.

  • To deal with future high-cost oncology therapies. Because many future oncology treatments will likely be very expensive, it will become even more important to justify these costs. This is especially true when benefits are limited or when evidence of improved effectiveness is minimal.

In many countries, economic evaluation has become an integral part of coverage and reimbursement decisions that are made on a national level. In the United States, in private health plans, economic evidence is often incorporated in formulary and reimbursement decisions, but in the public sector, the decentralized healthcare system has contributed to the lack of economic evaluation of treatment.

Dr. Shih pointed out that for most outpatient prescription drugs, if a generic formulation is available, clinicians are encouraged to use it. "For cancer drugs, things can be more complicated because drugs with similar efficacy can have a very different side-effect profile, and some side effects can cause a major reduction in patients' quality of life," she said. "Therefore, if a generic version of an infused drug offers almost the same efficacy as a branded oral drug and if both drugs have a similar side-effect profile, then choosing the generic option should be supported both clinically and economically."

"If the side-effect profile differs substantially, then the decision becomes more complex; that's where methods such as a cost-utility analysis will help," she added.

The authors put together this paper to raise awareness of economic issues among practicing oncologists. "We hope that this information will prompt practicing oncologists to include economic issues...when they discuss treatment selections with their patients," said Dr. Shih.

CA Cancer J Clin. 2008;58:231-244. Abstract.


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