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Journal of Clinical Oncology, Vol 25, No 15 (May 20), 2007: pp. 2142 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.10.7540
Communicating With Patients About Chemotherapy CostsProvincial Systemic Therapy Program, British Columbia Cancer Agency, Vancouver, British Columbia To the Editor: Schrage and Hanger1 provided a very helpful gleam on how medical oncologists viewed their responsibilities in communicating with patients about chemotherapy costs. There are two key issues that can be further elaborated. First, although many may think that they do not usually take cost into account when recommending a treatment, the truth is that we all do, if only subconsciously. Recommendation of a treatment, even when cost is not explicitly discussed, is based on the assumption that there are resources (somehow) to support the delivery of the treatment. To take an extreme theoretical example, would one recommend a treatment that can only be administered in zero gravity, or that would cost $1 billion per treatment course? Probably not, and the patient likely would concur that this is not a realistic option. The second consideration is that a treatment is not usually categorized as simply "works" or "doesn't work." More commonly, it works "a little" or "quite well." Clinical trial design, and regulatory approval, is usually based on proof of the minimal level of clinical improvement.2-6 However, this may not be enough when balanced against other factors like treatment costs, burden of disease, toxicity profiles, and so on. Funding agencies, such as the Centers for Medicare & Medicaid Services, define different levels of clinical improvement in global terms,7 such as "more effective" (improves by a significant, albeit small, margin as compared with established services or medical items) and "as effective but with advantages" (same effect as established services or medical items, but some advantages that some patients will prefer). However, this provides no indication of the true magnitude of benefit relative to the baseline prognosis of the patients. For example, 9 months may mean something different for patients with advanced small-cell lung cancer to those with, say, prostate cancer. Sunstrum et al8 showed that improvement in survival, tumor response, quality of life, and toxicity would classify a drug as being of "substantial improvement" for the purpose of setting a price by the Canadian Patented Medicine Prices Review Board. What is needed now is to relate the size of improvement in these end points to the baseline prognosis of the patients. Only then can we truly discuss how to communicate chemotherapy costs with the patients—and to the society at large. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author indicated no potential conflicts of interest. REFERENCES
1. Schrag D, Hanger M: Medical oncologists' views on communicating with patients about chemotherapy costs: A pilot survey. J Clin Oncol 25: 233-237, 2007 2. Freiman JA, Chalmers TC, Smith H Jr, et al: The importance of beta, the type II error and sample size in the design and interpretation of the randomized control trial: Survey of 71 negative trials. N Engl J Med 299: 690-694, 1978[Abstract] 3. Moher D, Dulberg CS, Wells GA: Statistical power, sample size, and their reporting in randomized controlled trials. JAMA 272: 122-124, 1994[Abstract] 4. Chan KB, Man-Son-Hing M, Molnar FJ, et al: How well is the clinical importance of study results reported? An assessment of randomized controlled trials. CMAJ 165: 1197-1202, 2001 5. Fayers PM, Cuschieri A, Fielding J, et al: Sample size calculation for clinical trials: The impact of clinician beliefs. Br J Cancer 82: 213-219, 2000[CrossRef][Medline] 6. van Walraven C, Mahon JL, Moher D, et al: Surveying physicians to determine the minimal important difference: Implications for sample-size calculation. J Clin Epidemiol 52: 717-723, 1999[CrossRef][Medline] 7. Medicare Coverage Advisory Committee-Executive Committee Working Group.Recommendations for Evaluating Effectiveness. Washington, DC, Centers for Medicare & Medicaid Services, 2002 8. Sunstrum CA, Carruthers-Czyzewski P, Carruthers SG, et al: The difficulty in assessing the relative therapeutic merit of new antineoplastic drugs. Canadian Journal of Clinical Pharmacology 4: 118-125, 1997 Related Reply
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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