Oncologists Still Avoid Discussing Cost of Care

Theodore Bosworth


August 07, 2017

Many professional medical organizations that provide guidance for cancer care now advocate a discussion of cost, including the American Society of Clinical Oncology (ASCO), which has urged physicians to do so since 2009. Few clinicians do, however, according to several sets of data.

The most recent and convincing data was based on recorded patient encounters. It was one of many presentations at the ASCO 2017 annual meeting, emphasizing how infrequently cost is discussed as well as the vast complexity of the topic.

Bankruptcies are three times more common in individuals with cancer than in those without, after matching for confounding variables.

One statistic was cited several times: Bankruptcies are three times more common in individuals with cancer than in those without, after matching for confounding variables. There is no reason to expect this to change. The newest and most effective oncologic drugs are increasing in cost at a time when affordable health insurance is becoming more uncertain. Cost specialists focus on the financial toxicity of cancer care, but clinicians remain largely out of the loop.

"You do not go to medical school to understand the cost of care and how it impacts your patients, but it is clearly becoming important to learn," said Rahma Warsame, MD, a research hematologist-oncologist at the Mayo Clinic, Rochester, Minnesota. She was among those who presented discouraging data on the infrequency with which clinicians discuss cost but acknowledged that the subject can be overwhelming. Clinicians do not typically have the tools to provide meaningful guidance.

At ASCO, Leonard Saltz, MD, a medical oncologist and chief of the gastrointestinal oncology service at Memorial Sloan Kettering Cancer Center, talked with Medscape about the importance of discussing treatment costs with patients.

"The major barrier to cost transparency is navigating the complexity and the variability of what is covered by the patient's healthcare plan," said Erin O. Aakhus, MD, assistant director of the Hematology/Oncology Fellowship Program at the University of Pennsylvania in Philadelphia. For patients, the most relevant issue is the out-of-pocket expenses, but Dr Aakhus, an ASCO-invited discussant on costs and value frameworks, indicated that evaluating each patient's healthcare plan for out-of-pocket costs is a challenging task.

Yet, the failure of clinicians to even consider the impact and the ability of patients to pay for the drugs they prescribe also poses risks. Copays increase the risk for nonadherence or discontinuation, even for potentially life-saving drugs. In a study of imatinib, also cited repeatedly during cost discussions, the rate of nonadherence increased 70% for copays above the median of $30 relative to those below.[1] This and other data suggest that clinicians who remain insensitive to costs may place their patients at risk for bad outcomes, particularly if solutions such as financial assistance or rebates are being overlooked.

Cancer patients hear about costs from physicians in 19%-41% of instances when therapeutic options are discussed.

But clinicians do not routinely discuss costs. In studies cited by Dr Aakhus, cancer patients hear about costs from physicians in 19%-41% of instances when therapeutic options are discussed. New data suggest that this may be an overestimate. In a unique prospective observational study in which patient encounters were recorded, the concept of cost was mentioned—not necessarily discussed—in just 28% of 525 recordings obtained at three sites in California and Minnesota. Physicians broached the subject in 30% of these cases and patients did so in 70%.

By itself, these statistics are disheartening, given the potential influence of cost on outcomes and patient financial well-being, but detailed analysis of these recorded encounters suggest that clinicians are resistant to cost discussions, not just slow to raise the issue. Evaluating the physician response in the 70% of cases when it was the patient, not the physician, who expressed interest in cost, the topic was only acknowledged by the physician in 60% of the cases.

"Forty percent of the time there was silence," reported the principle investigator of the study, Dr Warsame. She noted that in the 60% of the cases in which the topic was acknowledged, a direct action, such as a letter for insurance or change in medication, was taken in just 25% of cases.

The strength of this particular study is that it involved audio recordings of patients seen in an outpatient setting for solid tumors without any explanation of the purpose of the recording and, therefore, a low risk for bias toward the content.

The tapings provided "an ear in the room" and were systematically analyzed for cost discussions after being de-identified, according to Dr Warsame. Although costs could have been raised with any of the patients in another clinical encounter, the sample size of 525 recordings increases the likelihood that these conversations are representative.

Cost calculations are complex because it is not always clear what therapies will or will not be reimbursed at the time they are prescribed. However, even when out-of-pocket and other costs are known, they do not necessarily resolve affordability and value, particularly when expected benefit is limited and side effects must be endured. Value frameworks are therefore particularly critical when therapy represents a large financial burden. Several value frameworks are available, including one by ASCO that was updated in 2016,[2] but disparity between available frameworks underscores the complexity of assigning value.

In a study presented at ASCO that was specifically designed to compare frameworks, the correlations in value scores produced by those developed by ASCO and the European Society for Medical Oncology (ESMO) were weak to moderate, according to a team of investigators from the Sunnybrook Odette Cancer Centre, Toronto, Canada. When clinical benefit scores on specific agents were calculated with the two different frameworks, the low correlation coefficients demonstrated that the different methodologies provided disparate value calculations.

Furthermore, neither of the values from these frameworks "was significantly associated with recommendations from NICE [National Institute for Health and Care Excellence] or the pan-Canadian Oncology Drug Review," reported Sierra Cheng, a research assistant at Sunnybrook who presented the data. The United Kingdom's NICE, like the pan-Canadian Oncology Drug Review, uses its own methodology for establishing value for funding recommendations, but the divergence in recommendations reflects "different constructs of clinical benefit measured."

In other words, there is limited consensus on how to define value. This was reiterated in an analysis of clinician agreement with the National Comprehensive Cancer Network (NCCN) Evidence Blocks (EB). These are yet another tool for helping clinicians guide patients to therapies with value. The NCCN EB employs an analog format with values ranging from 1 to 5 to provide a visual representation of the efficacy, safety, and affordability of a given therapy. In an analysis presented at ASCO, ratings by surveyed oncologists showed only moderate consistency with the actual NCCN EB ratings. Drug costs were underestimated; out-of-pocket cost was overestimated. A separate survey question revealed that clinicians were not confident in their assessments.

"Only 26% of oncologists were comfortable or very comfortable with rating costs associated with affordability levels, and an equal proportion felt very uncomfortable," said Marco DiBonaventura, PhD, who was a senior vice president at Ipsos at the time of the study, which represented a collaboration of several pharmaceutical companies. He has since joined Pfizer. "It is noteworthy that there was no relationship between comfort and rating accuracy, so even those who felt very comfortable were not necessarily more accurate."

There is a lot of noise about the costs of cancer therapy and a growing clamor for clinicians to get involved in discussing costs with patients, but "this is not going to be easy," Dr Aakhus warned. The specific costs to the individual are difficult to calculate and are constantly evolving as patients change healthcare plans and healthcare plans change policies. So far, the data suggest that any discussion of cost occurs in the minority of patient encounters, let alone discussion that leads to action.

"Talk is not enough," Dr Aarhus maintained. Frank discussions that provide patients with real numbers and context to know what they mean are urgently needed even if there is concern about the utility and reliability of the tools that are now available.

Drs Warsame and Aakhus and Ms Cheng have disclosed no relevant financial relationships.

Dr DiBonaventura is an employee of Pfizer.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.