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Journal of Clinical Oncology, Vol 25, No 2 (January 10), 2007: pp. 169-170 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.09.9648
Perspectives on the Cost of Cancer CareAdvances in technology and understanding of cancer biology have lead to the introduction of a variety of new diagnostics and treatments in oncology. Many of these interventions are costly, and concern has recently been expressed that this cost is placing a tangible and increasing burden on patients and our society. There are many stakeholders in this issue, including patients, providers, drug and device developers and manufacturers, insurers, employers, and governments. The objective of this issue of the Journal of Clinical Oncology is to provide an introduction to the various perspectives on the rising cost of cancer care, to encourage informed debate on the topic. The first two articles are opinion pieces written by well-known health economists. These essays address a misleadingly simple question: "Is the rising cost of cancer care harmful to the economy?" These papers offer two perspectives that add texture and depth to the discussion of this critical issue. Mark Pauly argues that cancer spending does not harm the economy and posits the provocative assertion that current spending growth is actually of benefit.2 He explains that spending on cancer represents only a small portion of our gross domestic product, and that the value to be gained by ongoing investment in improved prevention and treatment strategies may trump cost concerns. In a companion essay, Scott D. Ramsey takes a somewhat different approach, stressing that our society had adopted an "anything at all costs" attitude regarding cancer care, and that demand for cancer care seems less dependent on cost than other health care services. 3 Ramsey argues that this inelasticity creates an incentive for the development of only marginally effective treatments and drives up cost, which ultimately has negative downstream effects given finite societal resources. Both authors emphasize that the evidence base for new treatments must be improved and ultimately used in patient management and perhaps allocation decisions. As an introduction to the concepts presented throughout this issue, the guest editors review estimates of the cost of cancer care and provide an overview regarding the macroeconomic principles that govern health care spending.1 We describe how the presence of insurance impacts consumer behaviors and how a cancer diagnosis may exert different influences on health care spending compared with other diseases. We outline how increased health care spending affects businesses and our economy, highlighting the potential for rising cost to exacerbate disparities in access. Overall, we seek to frame discussion on the complex and delicate balance that exists between the need to promote incentives for innovation of new cancer diagnostics and treatments and potentially competing societal fiduciary responsibilities. Any discussion of health care cost must consider the role of insurance. In the United States, the largest insurer is the government. Peter B. Bach, Senior Advisor at the US Centers for Medicare & Medicaid Services (CMS), explains the role that Medicare plays in the financing of cancer care. He describes the legal mandates that govern CMS decisions, structures that have historically hindered efficient delivery of care, and efforts underway to eliminate "perverse incentives" and reward quality care.4 He notes that ongoing efforts to collect data on both costs and outcomes can ultimately be used to reduce variations in resource utilization and improve quality of care. Health care delivery in Europe is distinguished from that in the United States insofar as the predominant model in Europe is a national approach with care delivery involving both the public and private sectors in a universal health care system. Michael Drummond and Anne Mason,5 health economists in the United Kingdom, describe the methods that European countries use to manage health care budgets and the costs of cancer care. These include governmental price controls, hospital formulary regulation, and formal economic evaluation in coverage decisions. The most well-established system that employs economic evaluation in health care decision making is the Technology Appraisal Programme of the National Institute for Health and Clinical Excellence (NICE) of the United Kingdom. This model is reviewed in detail by Drummond and Mason, with examples of oncology drug coverage decisions. Each of the economic assessments described above suggests that consideration of costs as well as benefits in health care decision making has potential merit. In an effort to inform policy discussions regarding cost-effectiveness analysis in cancer, we have invited two articles from health services researchers regarding this topic. Patrick A. Grusenmeyer and Yu-Ning Wong6 contribute a primer on the methodologies used to conduct economic analyses in oncology. They first introduce the nomenclature and concepts involved in cost-effectiveness analysis. The authors then illustrate application of these concepts with examples of recently published studies of cost-effectiveness of cancer prevention, adjuvant therapy, and treatment of advanced cancer. Amy B. Knudsen, Pamela M. McMahon, and G. Scott Gazelle next describe the use of modeling to evaluate the cost-effectiveness of cancer screening.7 They note the special limitations involved in conducting large-scale prospective cancer screening studies, and the types of estimation models used to overcome these limitations. Examples of lung, breast, colorectal, and prostate cancer screening programs are described. A common justification of the high price of cancer drugs is high development cost. Joseph A. DiMasi and Henry G. Grabowski,8 leading experts in this area, contribute a new analysis of oncology drug regulatory approval times, approval success rates, and international market diffusion based on publicly available data. Compared with other diseases, oncology drugs are more likely to obtain accelerated US Food and Drug Administration (FDA) approval status and faster FDA approval, though overall clinical development times are more prolonged. During the 10-year analysis period, approximately one in four oncology drugs that entered clinical testing ultimately gained approval, but only half the drugs entering phase III testing were approved. In first-in-class compounds and global diffusion, oncology drugs lead the way compared with other therapeutic areas. These findings underscore the current incentive structure for innovation in oncology drug development for the biotechnology industry. When considering the rising cost of health care, a question arises as to the ethical implications of cost containment strategies. Medical ethicist Daniel P. Sulmasy9 addresses the moral principles involved in reconciling the apparently conflicting premises that human life is priceless, yet health care resources are finite. He reviews and dismisses as unjust a number of cost-saving approaches, including bedside rationing, financial incentives to physicians, market-based approaches, government intervention, and the "averages" implicit in cost-effectiveness analysis. A provocative solution is offered in which Sulmasy rejects the notion that human life has a market value, while arguing that decisions regarding resource allocation are ethically permissible through application of "common sense rationing." Guidelines for the implementation of such a process are outlined. The final three manuscripts in this issue consider the impact of cost on the decision making of cancer patients and their oncologists. A behavioral science perspective is provided by Kevin P. Weinfurt,10 who offers prospect theory as a framework for understanding how and why the value propositions and treatment choices of cancer patients might differ from those of otherwise healthy individuals. Paula Kim,11 a leader in cancer patient advocacy, discusses the effect of both direct and indirect costs on patients' treatment decisions and receipt of care. A variety of available patient assistance resources are reviewed. Although oncologists are the primary sources of treatment information for cancer patients, little is known regarding the attitudes and practices of oncologists regarding the integration of cost into their treatment decisions and discussions with patients. In an effort to inform discussion on this issue, Deborah Schrag,12 a medical oncologist and health services researcher, along with Morgan Hanger, conducted a pilot study of oncologist attitudes. They report substantial variation in oncologist attitudes about discussing treatment costs with patients and whether cost-effectiveness should be considered in individual treatment decisions. Schrag and Hanger ultimately conclude with a suggestion that ASCO undertake an effort to define standards of practice with regard to the consideration and communication of cost information in treatment decision making. The implications of rising health care costs in general, and cancer care costs in particular are varied and complex. We hope that this issue of the Journal will help prepare the reader to be an active participant in critical policy discussions that impact the provision of cancer care for our patients. Further, we hope that some of the topics reviewed in this collection will help to deepen and extend the current discussion of the critical issues of cost, quality, and access to cancer treatment. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The authors indicated no potential conflicts of interest. AUTHOR CONTRIBUTIONS Manuscript writing: Neal J. Meropol, Kevin A. Schulman REFERENCES
1. Meropol NJ, Schulman KA: Cost of cancer care: Issues and implications. J Clin Oncol 25:180-186, 2007 2. Pauly MV: Is high and growing spending on cancer treatment and prevention harmful to the US economy? J Clin Oncol 25:171-174, 2007 3. Ramsey SD: How should we pay the piper when he's calling the tune? On the long term affordability of cancer care in the United States. J Clin Oncol 25:175-179, 2007 4. Bach PB: Costs of cancer care: A view from Centers for Medicare & Medicaid Services. J Clin Oncol 25:187-190, 2007 5. Drummond MF, Mason AR: European perspective on the costs and cost-effectiveness of cancer therapies. J Clin Oncol 25:191-195, 2007 6. Grusenmeyer PA, Wong Y-N: Interpreting the economic literature in oncology. J Clin Oncol 25:196-202, 2007 7. Knudsen AB, McMahon PM, Gazelle GS: Use of modeling to evaluate the cost-effectiveness of cancer screening programs. J Clin Oncol 25:203-208, 2007 8. DiMasi JA, Grabowski HG: The economics of new oncology drug development. J Clin Oncol 25:209-216, 2007 9. Sulmasy DP: Cancer care, money, and the value of life: Whose justice? Which rationality? J Clin Oncol 25:217-222, 2007 10. Weinfurt KP: The value of high-cost cancer care: A behavioral science perspective. J Clin Oncol 25:223-227, 2007 11. Kim P: Cost of cancer care: The patient perspective. J Clin Oncol 25:228-232, 2007 12. Schrag D, Hanger M: Medical oncologists' views on communicating with patients about chemotherapy costs: A pilot survey. J Clin Oncol 25:233-237, 2007 Related Correspondence
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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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