2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Sidebar 2. Five Changes in Oncologist Behavior
that Will Bend the Cancer Cost Curve
1. Target surveillance tests or imaging to those
situations in which a benefit has been shown.
2. For most solid tumors limit second- and thirdline
treatment for metastatic cancer to sequential
monotherapies. Based on the evidence,
single drugs are indicated in breast, lung and
prostate but not colorectal cancer.
3. For patients with cancer that has progressed
despite treatment, limit future chemotherapy to
patients with good performance status.
4. Replace the routine use of white-cell–stimulating
factors in the treatment of metastatic solid
cancers with chemotherapy dose reduction.
5. For patients not experiencing response to three
consecutive regimens, limit further chemotherapy
to patients entering clinical trials.
breast cancer guidelines with minimal testing will likely be
one of ASCO’s five topics in the American Board of Internal
Medicine “Choose Wisely” campaign.
Replace the Routine Use of White-Cell Stimulating Factors in the
Treatment of Metastatic Solid Cancers with Chemotherapy
Dose Reduction
The use of colony stimulating factors (CSFs) is one area
in which the United States and other countries have very
disparate patterns of care but no difference in mortality. 19
The United States represents 3% of the world population but
purchases 75% of the granulocyte (G-) CSF and pegylated
G-CSF produced by Amgen (Thousand Oaks, CA). We have
recently explored some of the reasons why this disparity
occurs, including dislike of febrile neutropenia, marketing,
fear of malpractice, and the profits made—often several
hundred dollars for each injection. The only proven recommended
uses are in dose-dense treatment for estrogenpositive
breast cancer and for lymphoma treatment when
the risk of febrile neutropenia is high. 20 A recent study
showed that for patients older than age 65, there was no
proven clinical benefit to the use of primary prophylactic
CSFs and that the cost-effectiveness ratio was more than
$900,000 per quality-adjusted life year saved, 21 which may
make us question current practice or demand lower CSF
prices.
We continue to recommend that the United States follow
the ASCO, NCCN, and European Organisation for Research
and Treatment of Cancer (EORTC) guidelines and use CSFs
for curative care. However, for the treatment of metastatic
solid tumors in which no clinical benefit has been shown, we
should follow ASCO and NCCN guidelines and use less toxic
regimens, not use primary prophylaxis even in diseases such
as small cell lung cancer (in which it is not recommended by
NCCN guidelines), and if needed reduce the doses per the
original protocol. We simply cannot afford $2200–4800 each
cycle for supportive care that does not improve survival
without the consequences in Sidebar 1.
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Sidebar 3. Five Attitudes that Must Change for
Better Cost Consciousness
1. Recognition that oncologists drive the costs of
care by what we do and do not do.
2. Both doctors and patients need more realistic
expectations.
3. Realignment of compensation to rebalance cognitive
services with chemotherapy use.
4. Better integration of end-of-life non–chemotherapy-oriented
palliative care.
5. Acceptance of the necessity for cost-effectiveness
analysis and the need for some limits on care.
Changing Attitudes
SMITH, HILLNER, AND KELLY
There are oncologist attitudes that also drive the cost of
care. We highlight two: recognition that oncologists drive
the costs of care by what we do and not do, and better
integration of end-of-life, non–chemotherapy-oriented palliative
care.
For instance, having a discussion about impending death
of a patient improves the pattern of care. Data show clearly
that although we discuss curability or not, 22 only 37% of the
time do we discuss the fact of an impending death. 23 Data
also show clearly that having this discussion was associated
with no more depression or anxiety in the patient; less
depression in the caregiver; far less end-of-life intubation,
resuscitation, and intensive care unit use; and longer hospice
use. Just having that discussion lead to better medical
care, better outcomes for the family, and $1,000 less spent in
the last week of life. 24
Sidebar 4. Integrating Best Practices: Use the
Medical Record to Help Your Practice
1. List the treatments used, so that we can know
when it is time to switch to non-chemotherapy
based care. Build in some prompts to trigger
consultation.
2. Put a prompt to remind you to discuss
Goals of care
Prognosis
Advance medical directives
“Code status”
Hospice referral
3. Have all patients with incurable cancer receive
a hospice information visit when they have 3 to 6
months to live, to make the transition smoother.
4. If you are not comfortable discussing these difficult
issues, appoint someone in your practice
(an advance practice nurse or social worker) or
get training.
5. After a patient is referred to hospice, pencil in
appointments to call them every week, just to
check on them and make sure they do not feel
abandoned.