October 5, 2011 (Stockholm, Sweden) — The cost of cancer care in high-income countries is becoming unsustainable, and a drastic shift in cancer policy is needed to rein in current costs, according to a report presented here at the 2011 European Multidisciplinary Cancer Congress, and published in the September issue of the Lancet Oncology.
The exploding cost of cancer care stems from factors that include the development of expensive anticancer agents and the overuse and rapid expansion of demand for both drugs and imaging techniques. There has also been a "tendency toward more defensive medical practice, a less informed regulatory system, and a declining degree of fairness to all patients with cancer," the authors of the report note.
Suggested solutions range from the reengineering of the macroeconomic basis of cancer costs to educating policy makers and creating an informed and transparent regulatory system.
"Political toleration of unfairness in access to affordable cancer treatment is unacceptable," write the authors, noting that 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."
High Cost of Care
Worldwide, about 12 million people are diagnosed with cancer ever year, leading to about 7.5 million deaths. The cost of new cancer cases worldwide was $286 billion in 2009; most high-income countries spend 4% to 7% of their healthcare budgets on cancer. With an aging global population and an "endless conveyor belt of expensive new drugs and technologies and increasing financial pressures," the ability to deliver affordable cancer care is stuck at a crossroads, say the authors.
In 2010, the estimated costs in the United States were approximately $124 billion; these are expected to reach $158 billion in 2020. However, if costs increase annually by 2% from the initial phase of care to the last year of life, the cost in the next decade will be closer to $173 billion.
The authors emphasize that the cost of cancer care in the United States is "increasingly burdened" by the off-label use of expensive therapies that provide marginal or no benefit.
Are we to simply let the train of affordable cancer care crash off the tracks?
Overall, cancer care is rapidly becoming beyond the reach of many Americans, except for the most affluent and the well insured, the authors write. Patients are faced with decreasing coverage of health insurance policies and increasing copays and deductibles.
The authous ask: "Are we to simply let the train of affordable cancer care crash off the tracks?" The consensus is that all parties involved need to address the issue right now.
A Complex Issue
Some of the barriers and proposed solutions to affordable cancer care are obvious; others are far more formidable and challenging. The barriers "reflect the fact that cancer is a complex disease embedded in equally complex and heterogeneous sociopolitical healthcare systems," the authors write.
Richard Sullivan, MD, from King's Health Partners Integrated Cancer Centre, London, United Kingdom, and lead author of the report, noted that "the affordability is no longer there and the macroeconomic systems simply cannot handle that level of expenditure."
At a press briefing, Dr. Sullivan explained that there are 3 main drivers of this problem. The first is sociodemographics; the population in developed countries is aging rapidly, and age is a major risk factor for cancer.
"By 2040, something like 25% of populations in developed countries, on average, will be older than 65 years," Dr. Sullivan said. "That's only going to increase, so is one of the biggest drivers."
"The second driver is what we call technocultural," he continued. "There have been huge increases in the number of new technologies — not only in medicine, but also in surgical techniques and devices and in imaging. It's great for cancer care, but incredibly difficult to manage from an affordability point of view."
In their report, Dr. Sullivan and colleagues note that during the past decade, there has been a marked increase in the number of novel systemic interventions, many of which are molecularly targeted agents. For example, in the United Kingdom, 35 oncology drugs were approved during the 1970s; today there are close to 100.
The third driver — macroeconomics — is a subject that people often forget about, Dr. Sullivan explained. It provides useful methods for understanding what is happening in cancer care.
"It is simply the pricing models of the healthcare systems that are leading to a major increase in the cost of salaries, infrastructure costs, and individual technologists," he added.
Adding the Costs
Incremental cost-effectiveness ratios are used to put a value on many of the technologies, Dr. Sullivan continued. "Very few clinical trials have embedded socioeconomic components, which is a huge missed opportunity," he said. "Furthermore, we really don't understand what the true costs are in many of our healthcare systems. Or if the costs are known, they are only known by certain groups."
"It's what we call the asymmetric information problem," Dr. Sullivan added. "We really have to say to healthcare systems that they need to find out what their real costs are and then link them to outcomes."
For example, molecularly targeted therapies might be revolutionizing the treatment of many types of cancer, but they are exceedingly expensive, and imaging costs are increasing twice as fast as the overall cost of cancer care.
Futile care also drive up costs. Education for both physicians and patients, research, personalized medicine, and more focus on end-of-life care can help determine when it is appropriate to stop therapy, the authors note. Appropriate end-of-life care not only spares the patient the potential toxic adverse effects of treatment that is futile, it also cuts cost.
Overuse is an issue, and can occur when physicians are unaware of the evidence. Time is also an issue; it is "sometimes quicker and easier to discuss a plan of treatment than to discuss why treatment might not be indicated." In the United States, the practice of "defensive medicine" is partly responsible for overuse; it can be driven by medicolegal concerns and the fear of missing something or failing to do everything, the authors point out. Finally, patient demand is an issue that can affect diagnostic studies and, ultimately, treatment.
Affordability and Wise Use of Technology
"We are in an era in which treatment is changing to multidisciplinary treatments, so patients are getting different treatments from different providers, and somehow all are related to cost," said Michael Baumann, MD, PhD, a radiation oncologist from the University of Technology, Dresden, Germany, and president of the European CanCer Organisation.
It's not one size fits all.
"We have a revolution of different treatment options for each patient, and we have to make decisions on which treatments are best for which patients," he explained at the press briefing. "It's not one size fits all."
As a patient, "you want the best and latest treatment and the hope that it is giving you access to better survival and a better quality of life," he explained. "It is absolutely correct and justifiable that the patient will have this perspective, but we have to see this perspective in the whole scenario. We also have to look at it in terms of affordability and fair access to those treatments for everybody."
Although much of the focus of debates about cost is on drugs, surgery remains the mainstay of curative treatment, the report notes. The majority of patients with solid tumors — around 70% — undergo surgery, they write.
"Surgeons see many of the cancer patients upfront," said Peter Naredi, MD, PhD, professor of surgery at Umeå University, Sweden, and president of the European Society of Surgical Oncology. "As we provide better techniques and better healthcare, we can operate on more patients and the cost can grow enormously."
"In surgery, there is a big focus on how to do less," Dr. Naredi explained at the press briefing. "An example is breast cancer — 30 years ago, the breast, lymph nodes, and axilla were routinely removed, but today, that is rarely done. A better strategy is to do a blood test, and not to do surgery in the axilla."
Dr. Naredi emphasized that new technologies should be used wisely. "An example is robot-assisted surgery," he said. "If we don't use it wisely, it will be extremely expensive. But if we use it wisely, we can use it so much that it doesn't cost the patient that much anymore. If we get good enough, it will decrease the complications, the sickness, the hospitalizations, and it can become cheaper than doing it the old way. But we need studies and need to develop strategies."
Issues Underlining Rising Costs and Possible Solutions
|Issues||Immediate Action||Research Needed|
|Increase in absolute amount and rate of expenditure for cancer care||Increase innovation in low-cost technologies, including the use of off-patent products||Develop business models to finance cancer care (along with fair compensation to practitioners), rethink pricing on drugs and other high-cost technologies, and develop new price-value models|
|Aging demographics||Mandate that elderly patients are included in clinical trials, taking into account issues such as frailty and the effect of comorbidities||Model the effect on cancer care and solutions for this demographic group in low- and middle-income countries|
|Rapid increases in technologic innovation||Raise the bar when developing technologies and decrease the number of marginal-benefit technologies that move to phase 3 trials||Use value-based pricing, in which both outcomes and costs are comprehensively measured during a full cycle of care|
|More patients lost to affordable cancer care||Determine out-of-pocket expenses and provide complete coverage plans for high-value treatments for all patients||Develop and test value-based models that use "real-world patients" and that include factors such as indirect costs and social aspects|
|Overuse of care by healthcare professionals and patients||Reduce the culture of futile care, aggressively control and curtail off-label prescribing, and promote evidence-based prescribing||Promote increased education of healthcare professionals, encourage patient/provider discussions on the use of less-intensive treatment options, and limit medicolegal litigation|
|Disconnection of regulatory and health-technology processes from each other and society||Align or merge conflicting regulatory and health-technology appraisal processes, and curtail regulatory bureaucracy on cancer research||Ensure a stronger understanding of clinical development by regulatory authorities|
|Poor intelligence for evidence-based policy making, and too much focus on minimal benefits||Promote the use of complex multimodal clinical trials (such as with high-cost technologies), and mandate integrated health economic studies in all clinical trials to accepted international guidelines||Reevaluate the methodologic basis of economic decision-making in cancer care|
|Fragmentation and heterogeneity of political prioritization for cancer in high-income countries||Initiate models for the delivery of transnational access and treatment, and hold nation states to an agreed-upon international cancer control plan|
If we don't make the decision for ourselves, someone else will.
Controlling the cost of care is a complex issue, said Dr. Sullivan, "and it needs to be treated like that."
"One of the key issues here is about drawing the debate back into the community, and for the community to take responsibility and to avoid this 'moral hazard' problem," he said. "It arises when an institution or individual doesn't take full responsibility for their actions and leaves another party to hold responsibility for the consequences."
"If we don't make the decision for ourselves, someone else will," he concluded.
Lancet Oncol. 2011;12:933-980. Abstract
2011 European Multidisciplinary Cancer Congress (EMCC). Presented September 27, 2011.
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