Roxanne Nelson

June 11, 2014

CHICAGO — The fundamental responsibility of oncologists is to ensure that all cancer patients receive the best possible care. But in the face of rapidly rising costs, what responsibility does the oncologist have ― if any ― to society as a whole?

This question was debated by experts here at the 2014 Annual Meeting of the American Society of Clinical Oncology, and although there was some divergence on viewpoints, there was also agreement.

"The professional norm is that the first and foremost responsibility of the oncologist is to do what is best for their patients," said Beverly Moy, MD, MPH, a medical oncologist at Massachusetts General Hospital in Boston, who chaired the session. "This norm is eroding in the face of ever-increasing growth of healthcare costs."

Physicians, as financial and professional stewards, have an obligation to serve not only individual patients but also society, she contended.

"Any way you slice it, it seems that technology and drugs are responsible for most of the costs in cancer care," said Dr. Moy. "And one can argue that oncologists have a responsibility, being that we are the prescribers. But oncologists can argue that we are not responsible for the costs."

In 2012, 9 of 12 new cancer therapies that received approval by the US Food and Drug Administration came with a price tag that exceeded $10,000 a month, she pointed out. Most have not shown prolonged survival in any of the trials. And for the few that did, the benefit was modest, generally between 10 days and a few months.

As healthcare costs rise along with the demand to somehow curb these costs, a consensus is developing that healthcare should be assessed on value. "But what is the value in cancer care?" asked Dr. Moy. "There is no consensus, and it really depends on which stakeholders you ask. We also have to figure out how to best measure value."

Duty to the Patient

Arguing for patient-centered care, Daniel Sulmasy, MD, of the University of Chicago, Illinois, noted that he "ascribed to the thesis that healthcare costs are spiraling out of control, especially in cancer, and that the oncologist does have a duty to control costs."

"What I vigorously object to is that it is best ascribed to at the bedside, by oncologists deciding how to or whether to treat an individual patient based on cost considerations," he added.

Dr. Sulmasy explained that clinical practice has "always has been and always will be about individual patients....Population medicine cannot be practiced at the bedside; the role of the physician is not to make the population well but to make the patient well," he said. Dr. Sulmasy also voiced alarm at calls for bedside rationing, especially when financial incentives are offered by third parties in relationship to bedside costs of care.

These incentives are morally problematic, he explained. "They threaten the integrity of medicine, and financial incentives undermine the patient's trust, who will wonder if the CT scan is not being ordered because it will not help or it will financially benefit the physician."

"We saw this under managed care, and how naïve can we be to think that this won't happen under the accountable care organizations," he added.

Taking the argument further, Dr. Sulmasy pointed out that financial incentives disrupt the delicate balance between profession, state, and market ― a balance that is needed in a complex society. These incentives turn the physician into an agent for the state.

"Bedside rationing is unlikely to achieve the goals of those who advocate it," he said.

Instead, physicians can help control costs by practicing "better wisdom in our bedside practice" and by using only as much treatment as is needed to make the patient well. "Overtreatment does not benefit anyone," Dr. Sulmasy added.

The same is true for diagnostics and by using only those tests that can help figure out how best to treat patients.

"I ask house officers, what is the point of getting a comprehensive baseline metabolic panel on a healthy 20-year-old?" he said. "But we do this all of the time."

Overall, he concluded, "our society as a whole must engage in a messy and uncomfortable but absolutely necessary political conversation about how much healthcare we can afford and how we can distribute it justly."

Duty to Society

In arguing for the duty to society, Reshma Jagsi, MD, DPhil, an associate professor in the Department of Radiation Oncology at the University of Michigan, in Ann Arbor, noted that Dr. Sulmasy had already made some of her arguments, in that oncologists have a duty to society as well as to the patient.

"He did discuss our duty to society," she said. "We are not that much in disagreement."

But although the moral duty to the patient is paramount in individual clinical encounters, physicians all have duties to society. "Healthcare is not like other goods, like selling shoes; it is a public good."

Dr. Jagsi pointed out that population health is influenced not only by medical treatment but also by other factors, such as education and social services. Thus, increasing costs of healthcare can "crowd out" these other essential services.

Resources are finite, and allocation must occur, she said.

She also agreed with Dr. Sulmasy that physician stewardship of society's scarce resources are best accomplished at the societal level rather than at the level of the individual bedside encounter.

"We must call attention to general areas of waste and develop solutions to improve efficiency," Dr. Jagsi explained.

She noted that there is a "lot of low-hanging fruit out there before we have to go after the true tragic choices, and it is our duty to call attention to those areas first."

An example of "low-hanging fruit" is the use of shorter courses of radiation therapy for palliation of bony metastases or adjuvant treatment of breast cancer. Both have been established as noninferior for selected patients in randomized trials. Embracing approaches such as these both reduces cost and improves patient-centered outcomes, such as convenience.

"There is not an argument that a patient would prefer 6 weeks of treatment as opposed to 3 weeks, unless the 6 weeks would produce a measurable benefit," Dr. Jagsi said.

But many situations are not that clear-cut, and she pointed to cases in which it is unlikely that the patient will derive a benefit and in which the cost to society is high, but the individual patient wants to go ahead with the therapy anyway.

"Here the physician's obligation to the patient and society conflict," she said. "I absolutely agree with Dr Sulamsy here that physicians must engage the public in setting priorities to guide their behavior in such circumstances."

An example of this is proton therapy for prostate cancer. It is reimbursed at a much higher rate than standard radiotherapy, but there is not enough evidence proving that it is a better option.

The overuse of resources on low-value care is another one of the many situations in which individually rational decisions can lead to collectively inferior outcomes, she added.

"If physicians focus exclusively on their duty to individual patients, they fail to uphold the full scope of their professional duties," Dr. Jagsi summarized. "Physician leadership to encourage public deliberation over priorities and value in healthcare is essential to avoid a tragedy of the commons."

The Choosing Wisely initiative is an example of how physicians are attempting to fulfill their duty to society while also respecting their duties to individual patients, she pointed out.

"Physicians cannot pretend that their sole duty is to the patient before them," Dr. Jagsi concluded. "Our privileged processional status comes with obligations to society, and we must eliminate clear cases of obvious waste, and we must be leaders in engaging our society in public deliberation over what constitutes meaningful benefit and value in healthcare."

"Resource allocation should reflect our shared moral understandings and priorities, and physicians must take the lead in preventing a tragedy of the commons," she added.

Dr. Moy and Dr. Sulmasy have disclosed no relevant financial relationships; Dr. Jagsi has disclosed relationships with Eviti and Abbott Laboratories.

2014 Annual Meeting of the American Society of Clinical Oncology.

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