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Originally published as JCO Early Release 10.1200/JCO.2008.20.1780 on December 15 2008 © 2009 American Society of Clinical Oncology.
Discussing Expensive Anticancer Drugs
Division of Haematology and Medical Oncology, Peter MacCallum Cancer Center, Victoria; Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Australia
Division of Haematology and Medical Oncology, Peter MacCallum Cancer Center, Victoria, Australia
Division of Haematology and Medical Oncology, Peter MacCallum Cancer Center, Victoria; Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Australia To the Editor: We read with interest the recent publication by McFarlane et al1 providing a six-step protocol for delivering bad news to patients about the cost of medical care. The significant cost of medical care affects clinicians, who report concerns with these discussions. Schrag and Hanger2 conducted a survey of 530 members of the American Society of Clinical Oncology and found that 26% of the 167 respondents rarely or never discuss costs with patients; 31% reported a high degree of discomfort discussing costs; and 16% acknowledged omitting treatment options on the basis of perceived ability to afford treatment. Discomfort with these discussions is not unique to US medical oncologists. In Australia, although many anticancer drugs are funded by the government and are available at no cost to the patient, there remain a number of drugs that are unfunded and must be fully paid for by the patient. We surveyed 274 medical oncologists in Australia and asked them to consider three hypothetical scenarios where a high-cost drug was associated with either improved survival, an encouraging response rate in a treatment-refractory cancer, or better tolerability and improved quality of life.3 If the drugs were available free, the vast majority of the 184 respondents would prescribe the drug; however, if the patient would have to pay for the drug, a significant number of oncologists would not inform the patient about this option (between 28% and 41%, depending on the scenario). Major reasons for not mentioning the high-cost option were concerns that the discussions might "worry the patient" or that the physician would "feel bad" discussing a drug that the patient might not be able to afford. Clearly, as McFarlane et al acknowledge, these discussions are challenging for medical oncologists. However, we believe that oncologists have a responsibility to discuss all treatment options.4 It seems this is also the wish of the general population. We recently surveyed a representative sample of the Australian population to ascertain their views about discussion of expensive anticancer drugs.5 We asked people to consider the same three scenarios as described in the survey of medical oncologists. Depending on the scenario, 90% to 98% of people wished to be informed about the option of an expensive drug, even though many would be unable to pay for these treatments.5 Patients need to be given information to make decisions that are right for them. Oncologists are often poor judges of the information needs of their patients, as well as their patients’ preferences for involvement in decision making. For example, Elkin et al6 asked 73 people with advanced bowel cancer and their 19 oncologists about their preferences with regard to information and decision making. Physician perceptions were concordant with patient preferences for information in only 44% of instances, and for decision control in 41%. We believe "there are no good reasons for withholding information about new unsubsidised drugs when reasonable evidence is available on safety and efficacy."4 We agree with McFarlane et al that communication skills training is needed and may assist both patients and clinicians with this difficult circumstance. Communication skills training for oncology professionals is effective7,8 and results in benefits for patients9 and for physicians.10 Determining a patient's clear understanding of prognosis and their expectations of treatment is essential in all circumstances and is relevant in circumstances where expensive drugs are a potential option.11 Particularly in advanced cancer settings, if there are misconceptions about potential benefits of treatment, people (including parents of children with cancer) are more likely to pursue futile therapies.12 We have suggested perhaps first discussing standard funded treatment options, then mentioning other unfunded options, asking whether the person wishes to hear more, and then providing details, including the costs of these options.3 As suggested, it may be useful to also encourage patients to raise questions about the cost of drugs.1 Question prompt lists increase question asking, including about sensitive areas such as prognosis.13 In addition to asking about treatment options, their effectiveness, and potential adverse effects, people might be encouraged to ask about costs. Given that the US and Australian surveys independently illustrate the difficulties of discussing this topic and as the use of expensive anticancer drugs is rising, open communication is an increasingly important component of good patient management. Oncologists are used to dealing with difficult communication situations. Improved communication skills can make these circumstances a little easier for patients, their families and friends, and for oncologists. We support the initiative of McFarlane et al to aid us in the difficult task of delivering bad news about the cost of medical care. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. NOTES published online ahead of print at www.jco.org on December 15, 2008 REFERENCES
1. McFarlane J, Riggins J, Smith TJ: SPIKE$: A six-step protocol for delivering bad news about the cost of medical care. J Clin Oncol 26:4200-4204, 2008 2. Schrag D, Hanger M: Medical oncologists’ views on communicating with patients about chemotherapy costs: A pilot survey. J Clin Oncol 25:233-237, 2007 3. Thomson J, Schofield P, Mileshkin L, et al: Do oncologists discuss expensive anti-cancer drugs with their patients? Ann Oncol 17:702-708, 2006 4. Jefford M, Savulescu J, Thomson J, et al: Medical paternalism and expensive unsubsidised drugs. BMJ 331:1075-1077, 2005 5. Mileshkin L, Agalianos E, Schofield P, et al: Patient preference for information about expensive anti-cancer drugs (EACD) that are potential treatment options. J Clin Oncol 26:345s, 2008 (suppl; abstr 6533)[CrossRef] 6. Elkin EB, Kim SH, Casper ES, et al: Desire for information and involvement in treatment decisions: Elderly cancer patients’ preferences and their physicians’ perceptions. J Clin Oncol 25:5275-5280, 2007 7. Gysels M, Richardson A, Higginson IJ: Communication training for health professionals who care for patients with cancer: A systematic review of effectiveness. Support Care Cancer 12:692-700, 2004[CrossRef][Medline] 8. Fellowes D, Wilkinson S, Moore P: Communication skills training for health care professionals working with cancer patients, their families and/or carers. Cochrane Database Syst Rev CD003751, 2004 9. Back A: Patient-physician communication in oncology: What does the evidence show? Oncology (Williston Park) 20:67-74, 2006; discussion 77-78, 83[Medline] 10. Armstrong J, Holland J: Surviving the stresses of clinical oncology by improving communication. Oncology (Williston Park) 18:363-368, 2004; discussion 373-375[Medline] 11. Schofield P, Carey M, Love A, et al: ‘Would you like to talk about your future treatment options’? Discussing the transition from curative cancer treatment to palliative care. Palliat Med 20:397-406, 2006 12. Wolfe J, Klar N, Grier HE, et al: Understanding of prognosis among parents of children who died of cancer: Impact on treatment goals and integration of palliative care. JAMA 284:2469-2475, 2000 13. Dimoska A, Tattersall MH, Butow PN, et al: Can a "prompt list" empower cancer patients to ask relevant questions? Cancer 113:225-237, 2008[CrossRef][Medline]
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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