Evidence-Based Oncology

The Oncologist Defines Value of Care

Published Online: August 21, 2014
Based on presentations by Reshma Jagsi, MD, DPhil; Daniel P. Sulmasy, MD, PhD; Beverly Moy, MD, MPH
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 escalating with no end in sight; estimated at $125 billion in 2010, treating cancer patients is predicted to cost the United States a staggering $175 billion in 2020.1 While the cost of newly improved drug molecules and drug delivery systems accounts for a significant part of these totals, several other factors contribute. Quality improvement measures (such as QOPI) and participation in the Choosing Wisely campaign adopted 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 in cancer care, as well as affordability issues and how they may come into conflict with respecting the patient’s individual wishes and needs.

The 3 physicians who participated in this session co-authored an article that was published online by ASCO: Value of Cancer Care: Ethical Considerations for the Practicing Oncologist.2

Beverly Moy, MD, MPH, clinical director of the breast oncology program at the Massachusetts General Hospital, Harvard Medical School, opened the discussion with her talk, “‘Value’ and ‘Values’ in Cancer Care: Can We Balance Our Duties to Patients and Society?” Moy began 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 or event-free survival. 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 are no data on adjuvant treatment.

The cost of cancer care is skyrocketing. The National Institutes of Health estimated the total cost for cancer care for the year 2009 at $216.6 billion, and cancer therapy takes up 5% to 11% of the national healthcare budget. Asked 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.” Moy went on to emphasize that practicing oncologists are the gatekeepers of chemotherapy and patient care, and so in some way are responsible for the cost. Six of the 8 drugs approved by the FDA in 2013 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,” said Moy.

Moy ended 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 lifesaving 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.” His research interests include end-of-life decision making, ethics education, and spirituality in medicine.3

As the speaker before him, Sulmasy began 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 of 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 both, he said—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 Sulmasy. Medicine has historically been treated as a business. However, given the necessity of access to medicine, it should be considered 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,” said Sulmasy. “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. 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. 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 Oncologist’s Duty to Society,” 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 proved that healthcare spending crowds out other spending in social services that are essential to promote health. Additionally, the rising cost of care 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 intuitions, as well as to reduce waste to maximize the value of our interventions,” said Jagsi.

She affirmed that 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, a shorter course of radiotherapy for preventing bone metastases or for adjuvant treatment of breast cancer. Embracing such an approach could reduce cost and improve outcome as well. Another easy fruit to pick is utilizing cheaper therapy with the same outcomes. Jagsi believes it’s not just about financial incentives—oncologists are a little nervous about adopting cost-saving changes when they lack a clear understanding. An example of a more difficult decision to make would involve a patient who is unlikely to benefit from a treatment with high costs for society, but who demands to be administered the drug. This would create a conflict for the provider, who would have to balance his obligation to society with obligation 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.

Jagsi left the audience with the following words of wisdom from Howard Brody, MD, PhD, director of the Institute for the Medical Humanities:

“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 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.” EBO

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-valuecancer-care-cost-cancer-drugs-and-technologies. Accessed June 1, 2014.

2. 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.

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