Considering the Cost of Cancer Care in Treatment Decisions

Words like value, quality, and even cost flowed freely at the ASCO Annual Meeting this year. Along with great excitement about the latest and greatest ways to understand tumor biology and treat cancer patients, there is an increasing recognition that we need to consider whether the things we do are worth it. As an oncology fellow, I have seen how cost affects not only payers but also providers and patients. Yet, cost is still a taboo subject in the United States, one that is better left unmentioned when we decide how to care for our patients.

The subject, not surprisingly, was discussed at several Health Services Research sessions that I attended at ASCO. In “The Present and Future of the State of the Art in Health Services Research,” problems with our current fee-for-service system were outlined. Payment is given for doing more-but for delivering more expensive care instead of better care. The discussants told us that financial incentives do affect oncologists, and that we need to move toward aligning reimbursement with delivering high-quality care. But the only way to work on such an alignment is to actually talk about it more openly. Various professional medical societies either consider costs explicitly, implicitly, or not at all. We were told that ASCO falls in the middle right now, where costs are only implicitly considered.

In the oral abstract sessions for Health Services Research, cost-effectiveness was discussed on a more tangible level. One abstract was titled “Bevacizumab in Addition to 5-Fluorouracil–Based Chemotherapy for Metastatic Colorectal Cancer: A US-Based Cost-Effectiveness Analysis for 1st and 2nd Line Therapy” and was presented by Daniel Goldstein, MD. Using Markov models, the authors calculated the cost-effectiveness of using FOLFOX with or without bevacizumab. They found that the incremental cost-effectiveness ratio (ICER) for the addition of bevacizumab to chemotherapy was $240,195 per quality-adjusted life year (QALY), and using bevacizumab in the second line yielded an ICER of $219,724/QALY.

The threshold level for an ICER in the United States is still a matter of great debate. The authors of the study mentioned that $50,000–$100,000/QALY is acceptable. Sandra Wong, MD, subsequently discussed the study and she thought that the threshold value for an ICER should be $150,000/QALY. Still, the numbers found in the bevacizumab study far exceeded any of these thresholds. The study was very well-conducted and described at ASCO; yet, I wonder if and how it will actually affect practice.

Will we actually stop adding bevacizumab to chemotherapy as a standard option for metastatic colorectal cancer because it is not cost-effective to do so? Certainly the benefit from bevacizumab is modest and the cost is quite high. If we are to curb the unsustainable growth of medical spending, things like using bevacizumab in this setting should be reconsidered.

As I reflect back on the ASCO meeting, this cost-effectiveness study also got me thinking about the plenary sessions. Nancy Davidson, MD, explicitly described cost of treatment in her discussion of endocrine therapy in premenopausal breast cancer patients. In the CALGB/SWOG 80405 study, we learned that bevacizumab or cetuximab plus chemotherapy are acceptable to use in the first-line treatment of metastatic colorectal cancer, and each yields an overall survival of 29 months. But I wonder: If bevacizumab is not cost-effective in this setting, perhaps cetuximab will not be either. Certainly, more cost-effectiveness studies using this new data could be informative.

As interesting as such cost-effectiveness ideas seem to me, I still wonder if we will change our practices based on them. Meaningful cost-effectiveness studies in oncology are now being performed, but will we have the guts to actually take action in response to the results?