ASCO 2014
The Oncologist Defines ‘Value of Care’
Earlier this year, the American Society of Clinical Oncology (ASCO) brought together the pharmaceutical industry, payers, providers, and patient advocacy groups to initiate a conversation on the challenges of defining value in cancer care. Annual costs in cancer care are through the roof and expected to be even higher. Estimated at $125 billion in 2010, treating cancer patients in 2020 is expected to cost the United States a staggering $175 billion.1 While the cost of newly improved drug moieties and drug-delivery systems add to the cost, several other factors can contribute. Quality improvement measures (such as QOPI) and the “Choosing Wisely” campaign initiated by ASCO, can help develop and promote high-quality, evidence-based care.

Healthcare providers play an extremely important role in choosing the right treatment and care option without compromising the quality of care. On the second day of the 50th annual meeting of ASCO, “The Value of Cancer Care and the Professional and Ethical Obligations of the Practicing Oncologist: A Debate” delved into the ethical issues raised by the economic reality of the rising costs of cancer care for the practicing oncologist. The presenters discussed the potential conflict between costs and value of cancer care, and affordability issues and how they may come into conflict with respecting the patients' individual wishes and needs.

Beverly Moy, MD, MPH, clinical director of the breast oncology program at the Massachusetts General Hospital, Harvard Medical School, opened up the discussion with her talk, ““Value” and “Values” in Cancer Care: Can We Balance Our Duties to Patients and Society?” Dr Moy started with an example of a 32 year old woman with HER2+ breast cancer without metastatic disease. The dilemma in this case was in addition to adjuvant chemotherapy and trastuzumab, could she be administered pertuzumab? Pertuzumab is priced at $4890 to $6000 per cycle. Pertuzumab was granted accelerated approval by the FDA as neoadjuvant therapy for HER2+ early stage breast cancer, however there are no data demonstrating improved overall survival (OS) or event-free survival (EFS). Additionally, no data demonstrating its efficacy in the adjuvant setting are available.

Another example was of a 38 year old woman, with ALK+ lung cancer. She had stage T2aN1 non-small cell lung cancer (NSCLC) with ALK rearrangement but no metastasis. The dilemma with this patient: is there a role for crizotinib in the adjuvant setting? Crizotinib, which costs $9200 to $12,000 per month, improves response rate and progression-free survival with ALK rearrangements, but there is no data on adjuvant treatment.

The cost of cancer care is sky-rocketing. The 2009 estimated total cost for cancer care was estimated by the National Institutes of Health at $216.6 billion. Cancer therapy partakes 5% to 11% of the national healthcare budget. Asked Dr Moy, “Where is the major spending? Technology and drugs account for most of the costs, and chemotherapy takes up a major chunk of the drug cost.” Dr Moy went on to emphasize that practicing oncologists are the gatekeepers of chemotherapy/patient care, and so in some way are responsible for the cost. In 2013, 6 of the 8 FDA-approved drugs cost $10,000 per month. Alarmingly, most of these failed to show improved survival, and even if they did, the results were modest. “Where’s the value? The response to this question will vary based on the stakeholder who’s asked. There’s no consensus.”

Dr Moy wrapped up her talk by echoing the thoughts that were expressed in the value session on the first day of the meeting–no consensus has yet been reached in defining value.
The ethical dilemma arises because the oncologist’s duty is split between the patient and the society, and choosing a side is extremely difficult. The cost of this dilemma–patient deprivation of life-saving therapy.

Daniel P. Sulmasy, MD, PhD, professor of medicine and associate director at the MacLean Center for Clinical Medical Ethics at the University of Chicago, took the stage next to discuss, “Advocating for the Individual Patient's Good Should Be the Oncologist's Priority.” Dr Sulmasy studies end-of-life decision making, ethics education, and spirituality in medicine.As the speaker before him, Dr Sulmasy started the discussion by stating that costs in oncology have spun out of control and oncologists are responsible for controlling the costs. However, he argued that this cost control cannot be implemented at the patient’s bedside. Economics and public policy do not control bedside medicine–it’s about treating an individual patient and not the population. In the art of medicine, the individual patient is the interest: “Will this drug be useful to this patient under a particular circumstance?” However, science is concerned with population effects and not an individual patient. Clinical medicine is a blend of the 2; it involves science directed to an individual patient.

 “Population medicine cannot be practiced at the bedside. The goal is to improve the life of an individual patient and not the population,” said Dr Sulmasy. Medicine has historically been treated as a business. However, given the necessity of access to medicine, it should be considered as a public good and not a business. Patients should trust that the physicians are practicing medicine to improve their lives.

The question that arises, therefore, is how can we control healthcare costs without compromising on quality?

Bedside rationing and providing financial incentives can threaten the integrity of medicine. They also undermine the patients trust: is the CT scan ordered to increase personal income or do I really need it? Additionally, financial incentives disrupt the balance between the professional, the state, and the market.

In the absence of transparent and universally applicable rules, treatment will become unpredictable and idiosyncratic, and it will not achieve the goals of those who are advocating it. So the big question is: how can costs be contained in a morally appropriate manner and what’s the oncologists role?

Diagnostic elegance and therapeutic parsimony are the call of the hour said Dr Sulmasy. Diagnostic elegance translates into using only those tests necessary to diagnose a patient, while therapeutic parsimony means using adequate treatment, not overtreatment.

The session was wrapped up by Reshma Jagsi, MD, DPhil, associate professor of radiation oncology, University of Michigan. Dr Jagsi’s clinical practice and research are focused on breast cancer, but she is also actively involved in social, political, and ethical aspects of medical care. In her talk, “The Oncologists Duty to Society,” Dr Jagsi stated that physicians have a moral duty to society and they have a privileged professional role. They have an obligation to serve not only their individual patient, but also the society in general.

It has been proven that healthcare spending crowds out other spending in social services that are essential to promote health. Additionally, the rising cost of care also limits access by limiting the affordability of care. Rationing is no longer an issue of whether, but how. Resources are finite and allocation must happen. “Physicians owe it to society to help ensure that resources are allocated in a way that is congruent with broad moral intutions, as well as to reduce waste to maximize the value of our interventions,” said Dr Jagsi.

Physicians must be stewards to lead an evidence-based assessment of value, including studies to identify situations of overdiagnosis and overtreatment in healthcare. Eliminating waste is absolutely essential, and it could be initiated at the level of the easy low-hanging fruit. For example, shorter course of radiotherapy for preventing bone metastases of for adjuvant treatment of breast cancer. Embracing such an approach can reduce cost and improve outcomes as well. Another easy fruit to pick is utilizing cheaper therapy with the same outcomes. Dr Jagsi thinks it’s not just about financial incentives; oncologists are a little nervous about adopting cost-saving changes that they don’t have a clear understanding of.

An example of a harder decision to make would be a case where the patient is unlikely to benefit and treatment costs would be high for society, but the patient demands that he be given the drug. This would create a conflict for the provider, between his obligations to society versus to his patient.

The Choosing Wisely campaign by the American Board of Internal Medicine is engaging professional societies like ASCO to obtain therapeutic parsimony and diagnostic elegance. ASCO in turn has issued top 5 lists of opportunities to improve the quality and value of care.

Dr Jagsi left the audience with the following words of wisdom by Howard Brody, MD, PhD:  “The myth that physicians are innocent bystanders merely watching healthcare costs zoom out of control cannot be sustained.”

Her own final thoughts were, “We must eliminate the “easy 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.”

The 3 physicians who participated in this session have co-authored an article that was published online by ASCO: Value of cancer care: ethical considerations for the practicing oncologist.3

References

1.      ASCO holds leadership summit to address value in cancer care, cost of cancer drugs and technologies. American Society of Clinical Oncology website. http://www.asco.org/advocacy/asco-holds-leadership-summit-address-value-cancer-care-cost-cancer-drugs-and-technologies. Accessed June 1, 2014.

2.      The University of Chicago website. http://www.uchospitals.edu/physicians/daniel-sulmasy.html. Accessed June 1, 2014.

3.      Jagsi R, Sulmasy DP, Moy B. Value of cancer care: ethical considerations for the practicing oncologist. American Society of Clinical Oncology website. http://meetinglibrary.asco.org/content/11400146-144. Accessed June 1, 2014.
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