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See Inside August 2008

Cancer Doctors Ponder whether to Consider Cost in Treatment Decisions

In discussing treatments, cancer doctors plan to include cost

Oncologists will soon be adding “financial counselor” to their job description. With an increasing number of cancer patients suffering economic hardships as a side effect of expensive therapy, most oncologists are finding that cost needs to be considered as part of treatment options. Leading cancer organizations are now working on incorporating cost into treatment guidelines and other materials. The change, which departs from the current American medical ethos, is fraught with thorny questions not only for cancer doctors and patients but also for the health care system at large.

The U.S. spends about $200 billion annually on cancer care; many new drugs cost several thousand dollars monthly. For patients, co-payments represent the most severe sappers of bank accounts. Increasingly, insurers are holding patients accountable for up to 20 percent of the prescription price. Covered drugs being used off-label (for an indication not formally approved but still medically appropriate) can carry co-pays of up to 30 percent.

“Patients are having to make financial sacrifices related to treatment choice,” says Neal L. Meropol, an oncologist at Fox Chase Cancer Center in Philadelphia. High out-of-pocket costs have led many patients to forgo particular therapies. One study found that treatment-related expenses consumed 27 percent of the annual income among low-income cancer patients.

The concern also pertains to the societal impact of pricey treatments. Considering that many patients are Medicare beneficiaries, expensive drugs are devouring federal health care dollars, often for only minimal survival gains. As Meropol describes, the U.S. has shunned the rationing of health care embraced in many other countries: “That’s in part a cultural bias that no price is too high for an improvement in health.”

The integration of cost into cancer treatment guidelines could be signifying a broader shift in health care. “I do think we’re moving to a point where our society will start to be more comfortable with considering cost in decisions about what treatments we will pay for,” Meropol remarks. Some experts even posit that the no-holds-barred attitude drives up cost and that reining it in might lower drug prices to points that reflect what the market will bear.

Forthcoming guidelines from the two main U.S. cancer societies will offer the safe harbor of a standard approach for oncologists to follow when discussing cost. One is the American Society of Clinical Oncology (ASCO). Meropol, who is part of an ASCO task force studying the cost of cancer care, says that one first step is creating a database of co-pays for all cancer drugs charged by various insurance providers. The group is also focusing on research, physician education and patient support. As he sees it, “the task force’s overall goal is to make recommendations and develop tools to assist oncologists in dealing with issues of cost as they relate to quality oncology care.” Diane S. Blum, executive director of the patient-advocacy organization CancerCare, says that advocacy groups support these efforts. ASCO-issued cost guidance should come out this year.

The second set of guidelines is coming from the National Comprehensive Cancer Network (NCCN), a nonprofit alliance of 21 cancer centers. It has convened expert panels to compare drug regimens according to their effectiveness, toxicity and, for the first time, costs. The panels will weigh all these factors together in their recommendations for the best treatment options. Costs will also be added into the NCCN compendium of drugs and biologics. As with ASCO, the results of these efforts will start rolling out within the year.

But NCCN’s chief executive William T. McGivney has misgivings about trying to resolve cost issues in the clinic. He agrees that NCCN should address the needs of its customers (oncologists), but he sees this response as an unjust solution. “I think the organizations that are making substantial amounts of money off the health care system—the private payers and the drug companies—they ought to be the ones fighting this issue out,” McGivney says. Foisting the problem on patients, he points out, places an unfair burden on the constituency of the cancer care system that is the most taxed and the least equipped for complex, cost-versus-benefit analyses.

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