The pandemic has forced the field of oncology to make difficult trade-offs between cancer treatment and infection prevention. We need to be willing to make the same hard decisions around value.
In the face of COVID-19, the oncology field—like all of us—has had to accept trade-offs. With uncharacteristic speed, professional organizations in medical oncology and radiation oncology this spring developed and issued site-specific guidance for balancing cancer treatment against the threat of the coronavirus. Many of these recommendations—removing agents from chemotherapy regimens, delivering drugs or radiation therapy less frequently, or prescribing oral medications to be taken at home—accept small decreases in therapeutic effectiveness while reducing patient visits that increase the risk of exposure.
With such recommendations, COVID-19 has accomplished something that has long eluded the oncology field: It has forced us to weigh the value of cancer therapy against other serious concerns. A field that has had a laser focus on maximizing the duration of patient survival has had to make slight comprises as it grapples with an unpredictable and scary virus.
This is a new kind of conversation about value in oncology, one that is certainly easier because it involves balancing two competing health concerns. However, I'm hopeful that it kickstarts a larger discussion about value in the traditional sense—a discussion that we've waited too long to carry out as cancer costs have piled up. In 2018, spending on cancer drugs in the U.S. reached $57 billion, double the total from 2013. The average cost of a new cancer drug was $150,000 in 2017.
Among these expensive drugs, old and new, are true game changers that have extended lives by many years. But oncology is also rife with examples of therapies that dramatically increase the costs to our health care system while bringing relatively minor improvements. For pancreatic cancer, one drug increases survival a median of about 10 days while increasing costs by $7,000 a month. Another drug, when added to an adjuvant breast cancer regimen, increases the chance of a cure from 93.2% to 94.1%, but at a cost of an additional $80,000 to $90,000 dollars per patient. If you're among the two additional individuals in every 100 who are cured, it's a winning proposition. On a population level, however, what are the costs to our health care system and society if we routinely make this decision for all cancers? How else might we use that health care spending to save lives and improve society?
Answering such questions may feel impossible. For many of us, there is no price to put on an additional month of life, or on a slightly higher chance of a cure. But other countries have been grappling with such questions for decades. In the United Kingdom, for example, the National Institute for Health and Care Effectiveness evaluates whether the cost of a therapy justifies the incremental improvements it might bring to survival and quality of life. Drugs that fall below the threshold are not recommended to the National Health Service. Other countries, as well as the World Health Organization, also have methods for reaching these cost-vs.-clinical benefit analyses. However, the United States lacks a transparent process to carry out such deliberations, as Austin Frakt pointed out this month in a New York Times column.
"Deliberating openly and allowing public comment help reconcile our personal sense that we want limitless health care for ourselves and the collective constraint that there are limits to what society can afford," he concludes.
There are, of course, many therapies that are both more expensive and less effective, or no more effective, than other options. In a recent Lancet Oncology article, University of Zurich researchers examined 65 drugs for solid tumors and found, overall, no association between price and clinical benefit. Taking the less expensive option in these situations should happen with little debate.
But we also need to have the courage to have difficult conversations about those costly drugs that bring marginal benefit. And that need won't go away when the pandemic eventually subsides. Indeed, as we deal with the massive costs of the response to this crisis, we can expect greater pressure to manage spending on all types of care, including oncology.
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