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Journal of Clinical Oncology, Vol 25, No 22 (August 1), 2007: pp. 3383 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.12.6771
In ReplyFox Chase Cancer Center, Philadelphia, PA
Duke Clinical Research Institute, Center for Clinical and Genetic Economics, Duke University, Durham, NC When we initially proposed a special issue of Journal of Clinical Oncology devoted to the cost of cancer care to the editorial board, our objective was to inform and stimulate discussion regarding this complex and increasingly critical topic. In planning "Perspectives on the Cost of Cancer Care,"1 we were struck by the dearth of empirical research that had been conducted on the economics of cancer care. Clearly, this situation is improving, as evidenced by recent publications in JCO2-4 that stimulated the correspondence by Lopes and Gluck. In their letter, the authors address the importance of perspective in cost-effectiveness (CE) analyses, which serves as the basis for interpreting and applying these studies. The greatest value of CE analysis is to inform decisions regarding allocation of resources from a finite pot.5 A societal perspective takes into account productivity costs associated with cancer and its treatment. In most of the clinical literature, this perspective is not considered as (1) the empirical data are often shaped by social insurance policies within countries, (2) productivity costs have been found to vary little across treatment arms of a clinical trial (thus violating a parsimony objective of clinical research data collection), and (3) an important component of patient benefit, quality-adjusted survival, is already considered. From a theoretical perspective, these costs might be most important to consider when comparing treatments that offer different outcomes in terms of quantity and quality of life. The CE analyses regarding trastuzumab therapy in breast cancer highlight several issues regarding the cost of cancer treatment. First, expensive drugs such as therapeutic antibodies will appear less so in adjuvant compared with metastatic settings. Furthermore, drugs for which a method exists to select patients most likely to benefit (eg, human epidermal growth factor receptor 2 expression) will have an advantage in the realm of economic analysis, especially if price was set before the characterization of the subpopulation was made. Finally, Lopes and Gluck offer several alternatives to address ethical concerns over disparities in cancer care, including governmental price controls, market-based approaches, and restructuring of current incentive structures for innovation. Space does not permit us to review the pros and cons of each of these proposals; however, we agree that as a society there is an urgent need to address the disparities in cancer care (and health care in general) that are likely to become increasingly acute as health care costs escalate.6 The oncology community has an obligation to be informed and to participate in these discussions such that we may impact policy in service to our patients. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a "U" are those for which no compensation was received; those relationships marked with a "C" were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: None Consultant or Advisory Role: Neal J. Meropol, Genentech (C); Kevin A. Schulman, Genentech (C) Stock Ownership: None Honoraria: None Research Funding: None Expert Testimony: None Other Remuneration: None REFERENCES
1. Meropol NJ, Schulman KA: Perspectives on the cost of cancer care. J Clin Oncol 25:169-170, 2007 2. Liberato NL, Marchetti M, Liberato GB: Cost-effectiveness of adjuvant trastuzumab in human epidermal growth factor receptor 2–positive breast cancer. J Clin Oncol 25:625-633, 2007 3. Kurian AW, Thompson RN, Gaw AF, et al: A cost-effectiveness analysis of adjuvant trastuzumab regimens in early HER2/neu–positive breast cancer. J Clin Oncol 25:634-641, 2007 4. Hillner BE, Smith TJ: Do the large benefits justify the large costs of adjuvant breast cancer trastuzumab? J Clin Oncol 25:611-613, 2007 5. Schechter CB: Cost effectiveness in context. J Clin Oncol 25:609-610, 2007 6. Meropol NJ, Schulman KA: Cost of cancer care: Issues and implications. J Clin Oncol 25:180-186, 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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