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Journal of Clinical Oncology, Vol 26, No 25 (September 1), 2008: pp. 4200-4204 © 2008 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.15.6208
SPIKE$: A Six-Step Protocol for Delivering Bad News About the Cost of Medical Care
From the Department of Hematology/Oncology, University of Tennessee, Knoxville, TN; and Divisions of Hematology/Oncology and Palliative Care, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA Corresponding author: Thomas J. Smith, Division of Hematology/Oncology and Palliative Care, Massey Cancer Center-Virginia Commonwealth University, 1101 E Marshall St, MCV Box 980230, Richmond, VA 23298; e-mail: tsmith{at}hsc.vcu.edu Mr S takes you aside after his wife enters the chemotherapy room. "Doctor, how much longer is this going to continue? We already sold our house, but the 20% copay on our $14,000-a-month chemotherapy bills (paclitaxel, carboplatin, trastuzamab, and pamidronate) are adding up quickly. I'm glad she's doing OK, but do you think she'll last another 3 months? A year? I don't mean to sound morbid, but I need to plan." Mrs O is a 72-year-old rural widow on a fixed income and is enrolled in Medicare without supplemental insurance. She has stopped taking her aromatase inhibitor because she reached her "donut hole" of $2,400 for all of her chronic medicines. She searched for the least expensive medication, but 30 tablets of letrozole costs $266, anastrazole costs $279, and exemestane costs $266. Should she go back to generic tamoxifen at $22 per month? (All prices are from www.drugstore.com.). Ms S is a 43-year-old single mother whose metastatic breast cancer is shrinking on sixth-line chemotherapy with fluorouracil, leucovorin, and mitomycin injections 5 days in a row, monthly. She asks if you can do something else instead, because she cannot afford the daily $35 copayment. Your practice is obligated to collect this under insurance law. The breaking of bad news is universal to medicine, and particularly commonplace in oncology. There are several accepted ways to break bad news, including the use of a common format of structured listening to what the patient knows and wants to know, giving information in understandable amounts, reacting to the news, and checking for understanding. One of the most common protocols is the SPIKES protocol: establishing an appropriate setting; checking the patient's perception; determining the amount of information known, wanted, and to be transferred; knowing the medical facts beforehand; exploring the emotions raised during the interview; and establishing a strategy for support.1 Alongside clinical bad news, oncologists are increasingly confronted with giving economic bad news. The larger societal issues are well known: medical costs are inflating at a double-digit rate, which is unsustainable.2 Cancer drug costs to Medicare alone were $5.3 billion in 20043 and are likely much higher today. The cost of individual regimens for metastatic colon cancer has risen from a few hundred dollars to more than $30,000 per year;4 the added costs of bisphosphonates (up to $1,700 per dose), pegylated filgrastim ($2,700 per dose), diagnostic computed tomography scan ($2,500 per set) or positron emission tomography scan ($3,200 per scan) easily raise the cost of treatment to more than $100,000 per year per patient. Countering this bad news, there are equally important examples of medical good news about successes of new drugs, such as 2 additional months of survival with preserved quality of life using erlotinib (Tarceva [OSI Pharmaceuticals, Melville, NY], $3400 month) compared with placebo for advanced lung cancer.5 There is growing evidence that patients are feeling the pinch, too. Copayments for some drugs have risen to as much as 20%. For a regimen such as carboplatin, paclitaxel, and bevacizumab for advanced non–small-cell lung cancer, the copay itself could be as much as 20% of $17,000 per month. In one study,6 the median out-of-pocket expense for 156 women receiving breast cancer therapy was $1,455 per month, and all of these women had some form of health insurance. On a fixed income this is not manageable, and given that this study was published in 2004, the costs are, no doubt, higher today. Additionally, out-of-pocket costs tend to mirror medical expenditures, and we know of several patients in our own practice for whom these issues have become paramount. Patients have sold their homes, tapped other resources such as college funds, switched from aromatase inhibitors (about $270 per month) to tamoxifen (available for as little as $10 per month via the Internet) for breast cancer, asked if the practice can forgo the $35 to $50 copayment for each daily visit, or, too commonly, just stopped coming for treatment. In our own practice, during one short discussion, we quickly named more than a dozen patients whose finances had changed their care options. Some of these issues came to the billing manager, and some large denials from insurance companies came to individual physicians, but we are concerned that most cost issues never came to the attention of the physicians. There are only a few ways to reduce the costs of medical care: reduce the services provided by payer-provider mechanisms such as lowered reimbursement; reduce the services provided by payer-patient mechanisms such as higher copayments, more restrictive covenants, or formalized guidelines with limits to care; or reduce the cost of the service such as by paying less for drugs or providers, or by paying for treatment only when it is effective.7 We do not see most payers promulgating "stopping rules" for expensive chemotherapy,8 or implementing treatment-specific caps, because that would cause too much bad publicity. In addition, patients have differing preferences for treatment,9 so one rule will not fit all. Hence, the job of lowering cost will likely be carried out with increased copayments and practice monitoring, and the job of discussing the issues will trickle down to oncologists and their business offices, whether we like it or not. We searched the literature for how oncologists are taught to discuss monetary concerns with their patients, and found limited information from PubMed and Google using the terms "medical oncology economics," "patient information," "patient costs," and "patient copayments." With apologies to Dr Robert Buckman,1 we propose a modification of the SPIKES protocol to include financial concerns, which we term SPIKE$ (Table 1.).
We do not know yet how common this problem is, but suspect it is a common stress to patients and families, and to some physicians who become involved in the details. As for discussions of prognosis, choices for treatment of advanced disease, sexuality, and psychosocial stress, we expect that patients will not volunteer much information unless queried. We also suspect that patients’ need for information will change over time, with the course of the cancer, and that people will change their minds about how much information they want to know and discuss with their doctor.10 A simple screening question such as the one for depression, "Are you depressed,"11 modified to "Are you having financial worries about your treatment," seems to be enough to engender responses. This may also be an important follow-up issue for families of the 20% of Medicare patients12,13 and a likely higher portion of insured patients who are receiving chemotherapy within 2 weeks of death (and who will not live to see the bills). We can modify our usual patient-physician discussion form to include financial issues (Fig 1). Such prompts have been shown to be useful in several other oncology situations.15-17
Physicians most likely would prefer not to discuss these difficult issues, just as many of us would prefer not to discuss advance directives,18 prognosis,19,20 and other issues for which there is not a quick medical fix. As with end-of-life and palliative care discussions, lack of reimbursement may be seen as a formidable obstacle by many oncologists.21 If we want patients and families to make the most informed decisions, the oncologist must give an honest and realistic estimate of the benefit of a treatment and put that in terms relative to its cost. For a curative treatment where someone is likely to live many years after receiving it, they may be willing to pay large amounts or go into large amounts of debt to finance it. But for some of our treatments, (ie, cetuximab for metastatic colorectal cancer, at a cost of $30,000 for 8 weeks of treatment—for a median 6-week survival advantage22) this trade-off is just not worth it for some patients, possibly leaving their family with a debt they cannot repay. Patients may prefer not to discuss these issues with their treating physician, and prefer to discuss them (if at all) with an anonymous person such as someone in the business office, who is not involved in the difficult decisions about treatment, as Lamont and Siegler23 found regarding discussions about advance directives. In that study, of 101 patients hospitalized with cancer who had not discussed advance directives with their oncologists, only 23 desired to do so, but most would support discussing the issue with the anonymous admitting physician. Other work has shown that most patients do not want to hear of any financial incentives that their physician might have, and are uncomfortable even broaching the subject; they might want to know if the incentives had any impact on them personally, such as copays.24 Most patients would probably be surprised to know that there is some evidence that reimbursement does not change the decision to administer chemotherapy, although oncologists seem to choose the chemotherapy programs that generate the most income for the practice.25 Most of the published experience from interviews of terminally ill cancer patients26,27 and focus groups of people receiving treatment28 report that patients want their physicians to be straightforward, honest, and involved in their care even when chemotherapy is no longer being given, and to "stay the course." Almost all of the data suggest that patients want us to give them the most complete information available, even if they choose to ignore it or misinterpret it, as they often do, and that they want such information not to take away hope.29,30 To conclude, oncologists should be prepared as much for the economic issues that affect our patients as we are for clinical issues. Having a straightforward technique to discuss the issues may help. New research efforts may facilitate our understanding of these issues first explored more than 10 years ago (Table 2).31
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
NOTES Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article. REFERENCES
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Benner SE, Fetting JH, Brenner MH: A stopping rule for standard chemotherapy for metastatic breast cancer: Lessons from a survey of Maryland medical oncologists. Cancer Invest 12:451-455, 1994[CrossRef][Medline] 9. Matsuyama R, Reddy S, Smith TJ: Why do patients choose chemotherapy near the end of life? A review of the perspective of those facing death from cancer. J Clin Oncol 24:3490-3496, 2006 10. Grunfeld EA, Maher EJ, Browne S, et al: Advanced breast cancer patients’ perceptions of decision making for palliative chemotherapy. J Clin Oncol 24:1090-1098, 2006 11. Chochinov HM, Wilson KG, Enns M, et al: "Are you depressed?" Screening for depression in the terminally ill. Am J Psychiatry 154:674-676, 1997[Abstract] 12. Earle CC, Neville BA, Landrum MB, et al: Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 22:315-321, 2004 13. Emanuel EJ, Young-Xu Y, Levinsky NG, et al: Chemotherapy use among Medicare beneficiaries at the end of life. Ann Intern Med 138:639-643, 2003 14. Smith TJ: Tell it like it is. J Clin Oncol 18:3441-3445, 2000 15. Bruera E, Sweeney C, Willey J, et al: Breast cancer patient perception of the helpfulness of a prompt sheet versus a general information sheet during outpatient consultation: A randomized, controlled trial. J Pain Symptom Manage 25:412-419, 2003[CrossRef][Medline] 16. Brown RF, Butow PN, Dunn SM, et al: Promoting patient participation and shortening cancer consultations: A randomised trial. Br J Cancer 85:1273-1279, 2001[CrossRef][Medline] 17. Glynne-Jones R, Ostler P, Lumley-Graybow S, et al: Can I look at my list? An evaluation of a ‘prompt sheet’ within an oncology outpatient clinic. Clin Oncol (R Coll Radiol) 18:395-400, 2006[Medline] 18. Teno JM: Advance directives: Time to move on. Ann Intern Med 141:159-160, 2004 19. The AM, Hak T, Koeter G, et al: Collusion in doctor-patient communication about imminent death: An ethnographic study. West J Med 174:247-253, 2001[CrossRef][Medline] 20. Koedoot CG, Oort FJ, de Haan RJ, et al: The content and amount of information given by medical oncologists when telling patients with advanced cancer what their treatment options are: Palliative chemotherapy and watchful-waiting. Eur J Cancer 40:225-235, 2004[CrossRef][Medline] 21. Gelband H, Foley KM (eds): Improving Palliative Care for Cancer. Washington DC, National Cancer Policy Board, National Academy of Science. 2001 22. Cunningham D, Humblet Y, Siena S, et al: Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan-refractory metastatic colorectal cancer. N Engl J Med 351:337-345, 2004 23. Lamont EB, Siegler M: Paradoxes in cancer patients’ advance care planning. J Palliat Med 3:27-35, 2000[CrossRef][Medline] 24. Miller TE, Horowitz ER: Disclosing doctors’ incentives: Will consumers understand and value the information? Health Aff (Millwood) 19:149-155, 2000[Abstract] 25. Jacobson M, O'Malley AJ, Earle CC, et al: Does reimbursement influence chemotherapy treatment for cancer patients? Health Aff (Millwood) 25:437-443, 2006 26. Hagerty RG, Butow PN, Ellis PM, et al: Communicating with realism and hope: Incurable cancer patients’ views on the disclosure of prognosis. J Clin Oncol 23:1278-1288, 2005 27. Kirk P, Kirk I, Kristjanson LJ: What do patients receiving palliative care for cancer and their families want to be told? A Canadian and Australian qualitative study. BMJ 328:1343, 2004 28. Matsuyama RK, Grange C, Lyckholm LJ, et al: Cultural perceptions in cancer care among African-American and Caucasian patients. J Natl Med Assoc 99:1113-1118, 2007[Medline] 29. Harrington SE, Smith TJ. The role of chemotherapy at the end of life: When is chemotherapy "too much"? JAMA 299:2667-2678, 2008 30. Cherlin E, Fried T, Prigerson HG, et al: Communication between physicians and family caregivers about care at the end of life: When do discussions occur and what is said? J Palliat Med 8:1176-1185, 2005[CrossRef][Medline] 31. Bodurtha JN: What's this going to cost, Doctor? Acad Med 71:937-938, 1996[Medline] Submitted December 2, 2007; accepted January 22, 2008.
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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