We Can't Afford to Be 'Cost-Agnostic' With Our Cancer Patients

H. Jack West, MD


June 11, 2020

Years before entering medicine, Dr Fumiko Chino had the unenviable perspective of serving as the caregiver to her spouse with terminal cancer while they were a young married couple.

In retrospect, she confides that she was too embarrassed about the financial struggles she and her husband were facing to raise concerns that she needed to deplete her 401(k) account to pay for low-molecular-weight heparin with an out-of-pocket cost of up to $6000 every month. Although she now understands that warfarin is modestly inferior in efficacy, she and her husband would have appreciated the opportunity to decide whether it was a preferable choice, based on a wide-eyed view of cost versus benefit.

Likewise, she would have hoped to have been a more informed consumer about whether it was worth treating her husband's nausea with ondansetron, at $30 per pill, a choice that seemed to taunt her when she cleaned it up, undigested in his vomit, after struggling to get a bit of nutrition into him.

This life-changing experience spurred Dr Chino, a radiation oncologist at Memorial Sloan Kettering Cancer Center, to raise awareness of "financial toxicity," an increasingly adopted term for the potentially devastating impact on patients and their families presented by the cost of interventions to treat their illness.

With the cost of cancer treatments escalating at an astonishing rate, patients with cancer and their families face a significant risk for bankruptcy. Filing for bankruptcy has been linked to an increased risk for mortality following a cancer diagnosis. These financial burdens are also borne by insured patients undergoing cancer treatment.

Despite the crippling effects of financial toxicity, Dr Chino says that it remains terribly underappreciated by those of us making the treatment recommendations that lead to it.

Value Mindset Rarely Extends to Medicine

Every day, my wife and I make decisions about what to eat, where to go for our next vacation, or what home furnishings we should purchase. Though in each of these instances my vote counts slightly less than my spouse's, our priorities nonetheless resonate well and usually lead to a value-engineered decision.

This isn't to say that we routinely pick the cheapest drive-thru window option when choosing where to patronize for dinner, but we also aren't such discriminating foodies that we routinely justify meals at a fancier "four–dollar sign" restaurant. The more expensive meal is likely to be perceived as better than the local restaurant one that may offer greater value, but we weigh these factors to make an informed choice about how we spend our money.

This mindset rarely extends to medicine, an especially challenging setting where prices are often opaque and, when they can be determined, high.

Many physicians, myself included, have felt that our role is to recommend what we consider to be the optimal treatment approach in a "cost-agnostic" world. In fact, we may consider individualizing treatment recommendations by cost to patients as somewhat unjust. There are many moving parts in the cost of our treatments —so many, that considering them may leave us feeling overwhelmed. Thankfully, this hasn't stopped a wide range of efforts into at least beginning to address the issue of financial toxicity.

As an oncologist who has experienced the struggle of a spouse's cancer diagnosis, Dr Chino recommends simply taking a step toward seeing the perspective from the other side of the exam room door. She asks that physicians inquire whether the cost of care is a concern for their patients and family members, and then encourage them to feel comfortable in raising the issue in the future if appropriate. Having personally felt the embarrassment of confiding financial struggles to her husband's medical team, she knows that a physician destigmatizing this discussion is an important start. From there, physicians can consider less expensive but appropriate alternatives, in the hope of better value-engineering health care.

Remember the wise words from Samuel Shem's seminal medical text, The House of God: "If you don't take a temperature, you can't find a fever."

H. Jack West, MD, associate clinical professor and executive director of employer services at City of Hope Comprehensive Cancer Center in Duarte, California, regularly comments on lung cancer for Medscape. Dr West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing education programs and other educational programs, including hosting the audio podcast West Wind.

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