Optimal Cancer Care Across the Spectrum of Life and Disease

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The American Journal of Managed Care, May 2008 - Theme Issue, Volume 14, Issue 5

The Guest Editors set the context for this special collection of oncology-focused articles.

THE MAGNITUDE OF THE CANCER PROBLEMHealthcare costs in the United States have risen dramatically during the past several decades, now exceeding $2 trillion annually, or approximately 16% of the gross domestic product.1 The costs of cancer care represent approximately 10%, or roughly $200 billion, of which approximately 40% are direct medical expenditures.2-5 Although age-adjusted cancer incidence and mortality rates seem to have plateaued or even decreased during the past decade, the growth and aging of the population continue to present an expanding burden of newly diagnosed patients with cancer in the United States and worldwide. The American Cancer Society has estimated that during 2008 more than 1.4 million Americans will be newly diagnosed and that approximately 565,000 will die of this disease, with 45% of men and 38% of women expected to develop cancer during their lifetime.6 Cancer is the second leading cause of death in the United States but is expected to become the leading fatal disease within the next decade. Even now, cancer is the leading cause of death among those younger than 85 years.6 Lung cancer is the leading cause of cancer mortality among men older than 40 years and among women older than 60 years, second only to breast cancer among women aged 40 to 60 years. Although older persons may respond well to cancer treatment, they often experience a disproportionate degree of toxic effects associated with cancer treatment because of the effect of age on critical organs (such as bone marrow), requiring more aggressive support measures.7,8

PROGRESS AGAINST CANCER

The decrease in cancer mortality rates observed during the past decade, particularly among older persons, can be attributed in part to improvements in cancer screening, with earlier diagnosis. Early diagnosis among persons with access to effective cancer screening programs remains a critical factor in determining the stage of disease and subsequent mortality. The effectiveness of screening programs among older patients has been demonstrated. However, many clinical trials of cancer screening did not extend to the very old or to those with serious comorbidities. Providers of cancer care among older persons are often faced with difficult decisions in weighing the balance between the potential benefit and a patient’s limit life expectancy because of age and various comorbid medical conditions.9 Cancer screening programs are cost-effective among an otherwise healthy older population because of the greater prevalence of the disease and increasing life expectancy among the aging population.10

In an article in this issue of The American Journal of Managed Care by Resnick and McLeskey,11 the authors discuss the complex dynamics that clinicians must consider in cancer screening among older patients. They encourage providers to take an individualized approach to screening, balancing the benefits of early diagnosis with the potential harms, considering the patient’s health status and life expectancy, preferences, and quality of life. Cancer screening recommendations have been incorporated into various quality-of-care measures. In another study in this issue, Sarfaty and Myers12 discuss how the incorporation of quality-of-care measures for colorectal cancer screening into the Healthcare Effectiveness Data and Information Set by the National Committee for Quality Assurance resulted in many health plans revising their screening guidelines accordingly, with almost half establishing new or updated reminder and tracking systems.

Effect of DisparitiesAlthough cancer is largely a disease of aging, it affects all age groups, both sexes, and every socioeconomic stratum. Cancer mortality rates among African Americans exceed those among white subjects, a gap that continues to widen and is tied to educational and socioeconomic attainment. It should come as no surprise that the uninsured and underinsured, Medicaid enrollees, and racial/ethnic minorities are more likely to be diagnosed at advanced stages of disease.13

As reported by Roetzheim and colleagues14 in this issue, even among Medicare recipients with disabilities, there is heterogeneity of cancer care based on the type of insurance arrangement. Women with continuous health maintenance organization coverage manifested earlier-stage breast cancer and experienced better survival than those with mixed or fee-for-service insurance. Although variations among the patient populations in these settings may largely explain these differences, Medicare enrollees with cancer represent a heterogeneous population clinically and demographically and in their healthcare coverage.

Cancer Treatment

The costs of cancer care include not only cancer-directed treatments of surgery, radiation therapy, and systemic therapies but also the costs of managing disease- and treatment-related complications. Myelosuppression and its complications, including neutropenia, anemia, and thrombocytopenia, represent most of the dose-limiting toxic effects of cancer treatment. The economic toll of these complications and their treatment and prevention have been well studied.8,22,23

Lage and colleagues24 in this issue address the costs of treating skeletal complications, which may have a major effect on patient morbidity and mortality and on the cost of care in many types of cancer, including prostate cancer. The authors found substantial costs associated with conventional treatments such as radiation therapy and surgery. Increasingly, clinicians are turning to medical therapies to prevent these complications in high-risk patients with cancer. Although bisphosphonates remain the first-line choice for prevention of skeletal complications, concern about the toxic effects and costs associated with this class of drugs has led to the search for more effective or safer agents.25-27

TOTAL COSTS OF CANCER CARENonmedical and Out-of-pocket Expenditures

Few clinicians are unaware that many patients with cancer turn to alternative therapies to complement or to replace conventional cancer treatments. These choices may be driven by lack of effective therapies, fear of serious toxic effects, or distrust of conventional medicine and belief in naturopathic approaches. Direct costs associated with complementary and alternative therapies are a small proportion of direct medical costs but add substantially to the total costs of cancer care, including out-of-pocket expenditures.29,30 As pointed out by Lafferty et al31 in this issue, the use of alternative and complementary therapies is frequent, exceeding 50% of patients with breast cancer in their study. The use of these providers was similar across the natural history of cancer and was not limited to end-of-care situations.

CONCLUSIONSThe studies in this oncology issue of The American Journal of Managed Care highlight the rapidly changing healthcare environment faced by patients and families, healthcare providers, and payers. Great enthusiasm stems from new understanding of the molecular and genetic mechanisms of cancer, providing potential targets for effective diagnostic and therapeutic interventions. However, the continuing rapid rise in the costs of healthcare is a reality check on the relentless march toward a cure for cancer. Solid evidence of clinical efficacy and safety must remain the foundation for the approval and use of cancer therapies. The potential for managed healthcare plans to be leaders in the dissemination of effective cancer treatment and prevention strategies is considerable.

Efforts aimed at improving the quality of life of patients with cancer may begin with something as simple as decreasing wait times for treatment. In addition, we can learn from national health systems abroad that are providing greater access at lower per capita spending and are achieving better global healthcare outcomes.32

Author Affiliations: From the Division of Medical Oncology, Duke University School of Medicine and Duke Comprehensive Cancer Center (GHL), Durham, NC; and the Geriatric Oncology Consortium (RSH), Baltimore, MD.

Funding Source: None.

Author Disclosure: The authors (GHL, RSH) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (GHL, RSH); drafting of the manuscript (GHL); critical revision of the manuscript for important intellectual content (GHL, RSH); administrative, technical, or logistic support (GHL); and supervision (GHL, RSH).

Address correspondence to: Gary H. Lyman, MD, MPH, FRCP(Edin), Department of Medicine, Duke University, 2424 Erwin Rd, Ste 602, Durham, NC 27710. E-mail: gary.lyman@duke.edu.

2. Brown ML,Yabroff KR. Economic impact of cancer in the United States. In: Schottenfeld D, Fraumeni JF, eds. Cancer Epidemiology. New York, NY: Oxford University Press; 2006:202-214.

4.Yabroff KR,Warren JL, Brown ML. Costs of cancer care in the USA: a descriptive review. Nat Clin Prac Oncol. 2007;4(11):643-656.

6. Jemal A, Siegel R,Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008;58(2):71-96.

8. Lyman GH, Kuderer NM.The economics of the colony-stimulating factors in the prevention and treatment of febrile neutropenia. Crit Rev Oncology Hematol. 2004;50(2):129-146.

10. Lyman GH, Kuderer NM.The diagnosis and treatment of cancer in the elderly: cost effectiveness considerations. In: Balducci L, Lyman GH, Erschler W, Extermann M, eds. Comprehensive Geriatric Oncology. 2nd ed. London, England: Informa Healthcare; 2004:510-524.

12. Sarfaty M, Myers RE.The effect of HEDIS measurement of colorectal cancer screening on insurance plans in Pennsylvania. Am J Manag Care. 2008;14(5):277-282.

14. Roetzheim RG, Chirikos TN,Wells KJ, et al. Managed care and cancer outcomes for Medicare beneficiaries with disabilities. Am J Manag Care. 2008;14(5):287-296.

16. Ramsey SD, Martins RG, Blough DK,Tock LS, Lubeck D, Reyes CM. Second-line and third-line chemotherapy for lung cancer: use and cost. Am J Manag Care. 2008;14(5):297-306.

18. Lyman GH, Dale DC, Friedberg J, Crawford J, Fisher RI. Incidence and predictors of low chemotherapy dose-intensity in aggressive non-Hodgkin’s lymphoma: a nationwide study. J Clin Oncol. 2004;22(21):4302-4311.

20. Lyman GH. Chemotherapy dose intensity and quality cancer care. Oncology. 2006;20(14)(suppl 9):16-25.

22. Kuderer NM, Dale DC, Crawford J, Cosler LE, Lyman GH. Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients. Cancer. 2006;106(10):2258-2266.

24. Lage MJ, Barber BL, Harrison DJ, Jun S. The cost of treating skeletal-related events in patients with prostate cancer. Am J Manag Care. 2008;14(5):317-322.

26. McKeage K, Plosker GL. Zoledronic acid: a pharmacoeconomic review of its use in the management of bone metastases. Pharmacoeconomics. 2008;26(3):251-268.

28. Lyman GH.Time is money for both the healthy and the sick. Med Care. 2005;43(7):637-639.

30. Longo CJ, Deber R, Fitch M, Williams AP, D’Souza D. An examination of cancer patients’ monthly ”out-of-pocket” costs in Ontario, Canada. Eur J Cancer Care. 2007;16(6):500-507.

32. Ginsburg JA, Doherty RB, Ralston JF Jr, et al. Achieving a highperformance health care system with universal access: what the United States can learn from other countries. Ann Intern Med. 2008;148(1):55-75.