Cancer is a terrible disease that is terribly costly—as the tens of thousands of experts converging on Chicago this weekend for the annual American Society of Clinical Oncology (ASCO) meeting know better than anyone. An ASCO report earlier this year estimated that annual costs for cancer care in the U.S. will rise from $104 billion in 2006 to more than $173 billion in 2020.
An aging population more likely to develop cancer—combined with high treatment costs and rising prices for medicines and other new technologies—soon will place an unsustainable financial burden on individuals, private and public insurance systems, and society as a whole.
The antidote is a broad willingness to change how we determine and reward value in cancer care, develop new treatments, and learn from our successes and failures in helping patients.
The “we” in that last sentence must include the groups that our unlikely trio represents: cancer physicians, health-insurance companies, and the pharmaceutical industry. Consider us evidence that agreement is possible.
Not on everything, of course. The cancer physician (who also is a researcher) believes prices for cancer treatments are excessively high (five to 10 times higher than 15 years ago) and not justifiable based on the cost of research or cost-benefit calculations. He seeks other ways beyond the free market to reduce prices and drive innovation. The insurance executive (who also is a physician) wants his fellow oncologists to use lower cost options when multiple options producing the same results are available. The pharmaceutical executive (who also is a cancer patient) seeks wider acceptance of a free-pricing model for cancer treatments that hinges on demonstrated outcomes for patients.
Aside from these diverging views, however, there are at least three big reform paths that we and others do agree on taking.
First, we can and must define value in cancer treatments. We need such standards as the basis for making decisions about which treatments are worth prescribing and paying for, and what prices are fair ones. This is an immense challenge but we can learn from experiences in other countries and disease areas.
For example, value judgments should not be static as they are in some Health Technology Assessment systems abroad. The value of treatments evolves over time with insights from research and the practice of medicine—and so should decisions about the availability and price of these treatments.
The benefit of cancer treatments also should be viewed holistically. If treatments reduce costs elsewhere in the health-care system—perhaps by reducing hospital stays as effective HIV/AIDS treatments did—then this is an essential part of determining full value.
And value must take into account the things that matter to patients—life extension, certainly, but also reduced side effects and the ability to resume daily work and family roles during treatment. In the end, costs have to be justified by a significant improvement in patients’ prospects, and costs should be transparent when doctors and patients choose among treatment options. The common thread is that patients must be partners in assessing value and costs.
A second path forward is to reform clinical research in cancer. The established system of clinical cancer research is overburdened, bureaucratic, rigid, and unnecessarily complex—and the hurdles often do not add protection for patients or improve the quality of research. Instead, they can cause studies to fail for a lack of enrolled patients and they contribute to high costs, long delays, and shortened drug-patent lifetimes—essentially a losing proposition for everyone. There is no shortage of good ideas to reform cancer clinical research. What is missing is the will to overcome interest-group conflicts and move forward.
A serious agenda needs to include a reduction of the over-regulation surrounding clinical trials, with the explicit goal of increasing access for cancer patients. The percentage of cancer patients currently in clinical trials is less than 5 percent. It also would include reform of industry procedures and regulatory oversight to align with the new insights of the genomic revolution. The large scale trials used in the past are not invariably necessary as research divides more and more cancer patients into smaller groups based on their genetic information and potential response to treatment.
A third and final path is to prioritize the creation of comprehensive “learning systems” in cancer research and care. Much knowledge about what might or might not work against cancer simply is lost today.
To change this situation, industry and academia must embrace so-far tentative efforts to share insights from research without threatening intellectual property protections. Cancer physicians should capture lessons from patient care in accessible open databases. Insurance systems with troves of data on patient care and outcomes from medical claims also could offer insight on economic and scientific questions. ASCO’s CancerLinQ is a nascent example of the kind of databases that can improve decisions along the entire spectrum of cancer care from basic research into the treatment rooms and bedsides of patients.
It should not surprise us that cancer is costly when we lack a shared understanding of value, an efficient system to develop new treatments, and means to capture everyday lessons about this disease. Solutions are available to make cancer care affordable for all. It is time to implement them in a stepwise way—making cancer itself pay the price.
Kantajian chairs the Department of Leukemia at the M.D. Anderson Cancer Center; Newcomer is senior vice president, oncology, at UnitedHealthcare; and Crenshaw is vice president, oncology, for Eli Lilly.