NEJM: Rethinking cancer care & costs
As many in the political and public arenas argue that the costs of healthcare are on an unsustainable trajectory, physicians may be reaching their limits as well: the costs of care for oncology “are unsustainable” and require far-reaching changes in treatment and attitudes, among oncologists as well as patients, wrote the authors of a May 25 article in the New England Journal of Medicine (NEJM).

The annual cost of cancer care in the U.S. is projected to rise from $104 billion in 2006 to $173 billion in 2020, according to Thomas J. Smith, MD, and Bruce E. Hillner, MD, from the Massey Cancer Center at Virginia Commonwealth University in Richmond. “We must find ways to reduce the costs of everyday care to allow more people and advances to be covered without bankrupting the healthcare system.”

Partly in response to a challenge for each medical specialty to identify the top five wasteful tests and treatments, issued by Howard Brody, MD, PhD, in NEJM (2010; 362:283-285), Smith and Hillner issued a list of ten recommendations for bending the cancer cost curve without jeopardizing patient outcomes. All suggestions were directed at treatment for patients with incurable solid tumors only.

First among these proposals was unnecessary imaging. Citing the guidelines of the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN), Smith and Hillner stated, “There is no benefit to surveillance testing with serum tumor markers or imaging for most cancers, including those of the pancreas, ovary or lung, yet these tests are commonly used in many settings.”

The authors also argued that studies have showed that scheduled (as opposed to symptom-guided) imaging does not detect curable recurrences or alter survival. Scheduled carcinoembryonic antigen testing and CT for colon cancer present an important exception to this, they added.

“Changing practice will not be easy,” Smith and Hillner continued. Patients’ understandable desire for reassurance that cancer be detected early and the revenue generated by imaging and lab tests are attitudes that require fundamental changes. “[I]t can be troubling to both patients and doctors to confront the realization that detecting liver metastasis when the lesion measures 1 cm rather than 2 cm does not alter the prognosis,” the authors said.

More generally, the authors called on advocates for the implementation of routine testing with new technologies to justify their claims with randomized trials.

Smith and Hillner outlined measures that could reduce patient anxiety as an important byproduct of their recommendations. “To increase the use of effective testing strategies, we envision a multipronged social-marketing approach that would include printed guidelines distributed at office visits and support from advocacy groups, professional societies and insurers,” the authors wrote.

The authors also recommended limiting second- and third-line treatments for metastatic cancer to sequential monotherapies for most solid tumors and the replacement of routine white-cell-stimulating factor (CSF) use with a reduced chemotherapy dose in most metastatic solid cancers.

“We suggest a simple rule: patients must be well enough to walk unaided into the clinic to receive chemotherapy,” and for cancers that are unresponsive after three consecutive regimens, a switch to palliative nonchemotherapy care should be made. The authors suggested that both of these standards would merit some exceptions.

The change in cancer costs likewise requires a change in patient and physician attitudes. Referencing two studies, Smith and Hillner charged that oncologists only speak with a minority of cancer patients about death, which leads to unreasonable patient expectations and unproductive care. Another study found that a majority of lung cancer patients expected to live longer than two years, despite an average survival of eight months.

Finally, the authors emphasized that misunderstandings regarding the “death panels” discussed during healthcare reform debates hampered what needs to be a stronger emphasis on palliative care and greater reliance on hospice care, which, Smith and Hillman argued, evidence indicates is associated with longer, not shorter, survival.

As an overarching shift, the authors contended, “The need for cost-effectiveness analysis and for some limits on care must be accepted.” A transparent, equitable and politically independent agency that would offer guidance and make difficult choices for the public interest would be an important step, “so that doctors do not have to make them at the bedside," offered Smith and Hillner.

“We recognize that these changes will cause discomfort and adjustments, since all of them will inevitably result in dissatisfaction for important constituents such as patients, physicians or payors. However, we are convinced that we can take these steps if we work together as consumers, advocates, professional societies and payors. There really is no other way.”