2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

REDUCING THE COST OF CANCER CARE
Fig. 1. Expenditure per person on health care, in 2009 U.S. dollars.
From OECD Health Data 2011, http://stats.oecd.org/Index.
aspx?DataSetCode�SHA. 1
treatment with tamoxifen in estrogen receptor–positive
patients made absolutely no difference compared with treatment
when patients were symptomatic. 11 Early identification
of ovarian cancer recurrence with cancer antigen (CA)-
125 testing did not lead to better medical outcomes in a
large, well-designed randomized clinical trial. 12 There are
no data suggesting benefit in lung or prostate cancer for
early detection of recurrent disease, and screening is not
recommended. In fact, the only common disease in which one
can make a compelling argument is in colorectal cancer CEA
testing. 13
KEY POINTS
● Cancer costs are rising at an unsustainable rate—by
any measure.
● Oncologists are directly responsible for some of the
increase in costs, by what we do and what we do not
do, and are one key to bending the cost curve downward.
● We can reduce the cost of care by restricting surveillance
of patients who have received treatment to
those tests that have been shown to improve outcomes;
this will save several billions of dollars in
breast cancer alone.
● We can save several billions of dollars a year in
patients with metastatic solid tumors by reducing
the use of white cell growth factors to the indications
approved by ASCO, European Organisation for Research
and Treatment of Cancer, and National Comprehensive
Cancer Network, and with dose reduction
instead of colony-stimulating factor use where appropriate.
● We can improve care near the end of life by involving
palliative care and hospice earlier—3 to 6 months
before death—and, for most diseases by not administering
chemotherapy to patients with poor performance
status, or after progression despite three lines
of chemotherapy.
Sidebar 1. Some Facts about the Cost of Cancer
Care in the United States
● Medical care costs more in the United States than
any other country—often twice as much—with no
better survival. We spend $8,000/person/year versus
Canada’s $4500. 1
● Nearly one million 14 families suffered medical
bankruptcy in 2010. (Commonwealth Fund) Over
half of those bankruptcies happened to people
with insurance, and most families are middle
class. 2 Approximately 15% to 20% of insurance
payments are for cancer, so we caused several
them. Eight percent of families with a member
with lung cancer are bankrupt because of the
disease. 15
● The cost of insurance for a family of four has risen
from $6,000 to more than $15,000/year in the last
10 years. 16 No wonder more people are underinsured—up
to nearly 60 million—and others are
underinsured.
● Drug costs are rising at a rate of 3%, but represent
only 13% of the total cost of care. 3
● Much of the rest is under our control including
imaging, chemotherapy choices, integration of palliative
care, use of hospice, and avoiding chemotherapy
and hospitalization near the end of life. 4
● Oncologists’ salaries (median $381,992) are
among the highest for medical specialists compared
with primary care doctors ($202,392) and
rose 4% in 2010. This disparity is unique in
developed countries. 5
● At least half of oncologists’ income, 50% to 80%,
comes from drug sales which represent an inherent
potential conflict of interest, and is unique in
U.S. medicine. 5
● Hospitals have an inherent interest in keeping
beds full and profit margins high on drugs and
services.
● Approximately 25% of all Medicare funds are
spent in the last year of life, and more than 9%
(upwards of $50 billion) in the last month of life, 6
with similar patterns in commercial insurance.
The reason for the lack of effect on early recurrence has
been stated eloquently by Dr. Tito Fojo: “Until we have
treatments that kill essentially all the recurrent cancer,
rather than just some of it, we will not have a chance of cure”
(written communication, December 2011).
The reasons patients and maybe doctors want these tests
are complicated. Some patients want to be “doing something”
even if something is not of proven benefit. Explaining
the reasons behind not testing is more difficult and time
consuming than ordering the test. Using breast cancer as an
example, the ASCO printed guidelines that state “no testing”
can be reviewed in less than 10 minutes 17 and patients
can understand the rationale for not testing, 18 but it takes a
conversation that may be difficult for some oncologists.
ASCO is taking the lead in advocating for best practices
in cancer surveillance. Adherence to the ASCO and NCCN
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