Experts Question Benefits of High-Cost Cancer Care

Sandra Yin

December 05, 2011

December 5, 2011 (Washington, DC) — A conservative estimate of the number of targeted therapies tested in patients with cancer in the past decade is 700, yet no patients with solid tumors have been cured by targeted therapies over that time period, said Antonio Tito Fojo, PhD, head of the Experimental Therapeutics Section and senior investigator for Medical Oncology Branch Affiliates at the Center for Cancer Research at the National Cancer Institute in Bethesda, Maryland.

He was among speakers who looked at value in cancer care at a symposium on "Fighting a Smarter War Against Cancer." It was convened by the Ruesch Center for the Cure of Gastrointestinal Cancers at Georgetown Lombardi Comprehensive Cancer Center in Washington, DC.

"Zero [is] the number of targeted therapies that have prolonged survival by one year, when compared to a conventional treatment." Dr. Fojo noted in a talk that looked at the disconnect between the costs of cancer drugs and the magnitude of benefit they deliver.

In another example, Dr. Fojo noted that bevacizumab costs $90,816.00 per year to treat the average patient for breast cancer, yet it does not extend overall survival rate. Worse, he said, the chance that you'll experience a grade 3/4 toxicity if you give bevacizumab on top of paclitaxel more than doubles.

"This is not the innocuous drug that you were led to believe," he said. To tell a woman that you're going to have a 2-and-a-half-fold increase in toxicity and no benefit in terms of overall survival is unacceptable, he added.

The only "benefit," he said, was a prolonged progression-free survival of questionable value.

The disconnect between money spent and results is significant, said Thomas Smith, MD, FACP. He is director of palliative medicine at Johns Hopkins Medical Institutions and professor of oncology at the Sidney Kimmel Comprehensive Center in Bethesda, Maryland.

"The United States spends twice as much as any other country on cancer and medical care in general yet achieves the same survival, except for breast cancer and lymphoma, where you eke out maybe 1% to 2% better survival," he said.

With cancer care costs rising exponentially, Dr. Smith said it was time to change the efficacy and effectiveness curve by identifying therapies that deliver solid value.

Some therapies, such as imatinib for chronic myelogenous leukemia, "to use a baseball analogy, are truly home runs," said Dr. Smith. They are drugs that work so well, the question is: How are we going to pay for it? "Others are doubles or singles, where you get as [Dr. Fojo] said, 1.2 months, 2 months, 3 months — at the cost of substantial toxicity. "I would call those singles. Others are like sacrificed flies where you get 2 weeks."

Dr. Smith shared some of the ways to "bend the cost curve in cancer care."

"Target surveillance procedures to those most likely to benefit," he asserted. After a doctor has treated a patient for breast cancer, hoping to cure her, the only thing that helps the patient live the best life she can with the least chance of dying of recurrence is mammography — not blood tests or scans. Yet, in 1990, the United States wasted more than $1 billion doing tests on people who had been treated for breast cancer "with nothing to show for it," he said. The amount spent in recent years is probably even higher.

"Don't pay for these routine tests," he suggested. "Pay me to have a good survivorship care plan visit," where I can emphasize that you need to get your mammogram, and that I want you to eat lots of fruits and vegetables and avoid fat and meat, he said.

Another way to cut costs would be to limit chemotherapy to patients with good performance status. If they are fairly functional, they may benefit from chemotherapy.

If the person spends more than half the time in bed or a chair, you're just going to make that person sicker, rather than help them, Dr. Smith said. The risk for infection and toxicity are greater, yet the chance of benefit is near zero.

But it is not easy to call off chemotherapy. He told the story of a 67-year-old man who was suffering with severe abdominal pain from colorectal cancer. He had lost 20 pounds over the previous month and showed up in a wheelchair pushed by his wife. Dr. Smith called the oncologist and asked whether he had considered not treating the man with chemotherapy. The response he received was, "You want me to give up on him?"

Other pressures also may come into play. When Dr. Smith talked to a hospital administrator, he learned that if that doctor did not have so many of his patients hospitalized, the hospital would have one-third fewer hospitalizations and the institution would be way in the red. "It's a complicated web," said Dr. Smith.

One proven solution that reduces the chance chemotherapy will be pushed on patients who can't benefit from it is to document performance status, monitor oncologists' practices, and give feedback, Dr. Smith said.

At a University of Michigan faculty practice, too many people were getting chemotherapy within 2 weeks of their death. After giving feedback to oncologists, the number dropped from 50% to 20% in one quarter. "That's the beauty of feedback," he said.

After the day's many talks, including those by doctors, patients, insurers, big pharmaceutical companies, and government agencies, John Marshall, MD, director of the Ruesch Center for the Cure of Gastrointestinal Cancers, told Medscape Medical News that he felt the speakers had come closer to defining value in healthcare. He is also chief of hematology/oncology and associate director of Georgetown Lombardi Comprehensive Cancer Center.

"I actually felt a lot of clarity," he said. "The question is how to frame that in a way to have both government and industry, but most importantly, patient acceptance," he said, which would help barriers fall.

He noted that Dr. Fojo's and Dr. Smith's talks were well received by attendees. "They were just telling the truth," he said. "They recognize that to get to personalized medicine and get past the logjam we're in, we actually do need new regulations," he said. "We need an act in Congress…You have to start with why we need to change things. And they made a very clear demonstration of why we do."

Dr. Marshall said he dreams of a new law that would require drugs to be approved on the basis of value to the patient.

More information on the Ruesch Center's symposium can be accessed at the Center's Web site.

Dr. Fojo, Dr. Smith, and Dr. Marshall have disclosed no relevant financial relationships.

The Ruesch Center for the Cure of Gastrointestinal Cancers. Fighting a Smarter War Against Cancer: Linking Policy to the Patient. Presented December 2, 2011.

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