Five Myths About Cancer Care In America - Health Affairs

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At the Intersection of Health, Health Care and Policy

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Cite this article as: Dana P. Goldman and Tomas Philipson Five Myths About Cancer Care In America Health Affairs 33, no.10 (2014):1801-1804 doi: 10.1377/hlthaff.2014.0826

Cancer Care By Dana P. Goldman and Tomas Philipson 10.1377/hlthaff.2014.0826 HEALTH AFFAIRS 33, NO. 10 (2014): 1801–1804 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.

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Five Myths About Cancer Care In America

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uch has been made recently about the cost of cancer treatment, often played out in editorials in cancer journals or on the opinion pages of major newspapers.1,2 Some of the concern reflects beliefs that arose years ago when the illness was not as well understood. In this commentary we present some of the more common myths in America and the much more nuanced reality of today.

Tomas Philipson is the Daniel Levin Professor of Public Policy, Economics, and Law at the University of Chicago, in Illinois.

allow better quality of life. For example, longterm breast cancer survivors see an overall improvement in the two years following diagnosis,6 and delays in chemotherapy have been shown to negatively affect patients’ quality of life in some instances.7 So, while cancer still remains a pernicious disease, there is hope that it can be managed as a chronic illness, with modest side effects.

Myth 1: The War On Cancer Has Been A Failure

Myth 2: Detection, Not Treatment, Accounts For Most Of The Survival Gains

Perhaps no myth is so pervasive and yet so misguided than the one that declares that the war on cancer has been a failure.3 Today cancer patients live longer, healthier, and happier lives than those in prior decades. Survival rates for all cancers increased by almost four years during the period 1988–2000,4 creating twenty-three million additional life-years and generating $1.9 trillion in additional value to society, once the health gains are tallied.5 Survival rates have continued to improve in recent years. A rough comparison of these health benefits with spending on research and development—both private and public—suggests a substantial social return on investment. Furthermore, progress is being made in dealing with the extreme toxicity of chemotherapy and radiation regimens. Newer therapies often

The public’s attention often is drawn to the benefits of early detection. If a tumor is found earlier, it can be treated before metastasis and dramatically improve survival. Celebrities such as Katie Couric and events such as National Breast Cancer Awareness Month encourage screening, and new technologies have made detection more accurate and less invasive.8 The result has been that screening for some of the most common cancers has increased steadily.9 Thus, it comes as a surprise to many that treatment, not detection, has driven the majority of survival gains over the last few decades. During 1988–2000 almost 80 percent of the aforementioned survival gains were attributable to improvements in treatment, with the remaining 20 percent attributable to better detection. By some estimates, early detection accounted for O c to b er 2 0 1 4

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Dana P. Goldman (dana [email protected]) is the Leonard D. Schaeffer Chair and director of the Schaeffer Center for Health Policy and Economics, University of Southern California, in Los Angeles.

In this commentary we debunk a number of the most common misconceptions about cancer treatment, such as claims that the war on cancer has been a failure and that treatment costs are unsustainable. In addition, there is good evidence that patients value these treatments more highly than traditional cost-effectiveness analysis would indicate. We argue that coverage policies placing undue burden on patients are socially wasteful and will likely discourage further innovation. ABSTRACT

Cancer Care

Myth 3: Treatment Costs Are Unsustainable As noted earlier, the rising cost of overall cancer treatment—especially the contribution of highprice therapies—has drawn a lot of attention recently.1 However, this debate avoids a fundamental issue that is broader than cancer care— namely, that the focus should be on the price of health, not the price of health care services. An analogy with highly active antiretroviral therapy (HAART) to treat HIV is instructive. HAART, which was introduced in the 1990s, dramatically increased longevity for HIV-positive patients,13 although at a significant financial cost to these patients.14 Prior to the introduction of HAART, an HIV-positive patient could not buy a longer life at any price. The advent of HAART thus lowered the price of a longer life, although the price of treatment rose. Ultimately, more than 93 percent of the benefits of developing the new treatment accrued to patients in the form of longer lives, rather than to manufacturers.15 Similar declines were seen in the price of health for cancer patients, as measured by the price of each quality-adjusted life-year (QALY). Just over a decade ago, patients suffering from chronic myeloid leukemia faced grim prospects for survival. With the introduction of tyrosinekinase inhibitors (TKIs) in 2002, life expectancy increased by 5.5 QALYs, at a cost of $57,000 per QALY saved.16 Given that the value of a life-year in the United States falls in the range of $200,000– $300,000,17 TKIs seem like a good deal. Thus, society secured good value, even at brand-name prices. Next year, one of the first TKIs will lose its patent, and the price could fall dramatically as a generic enters the market. Of course, not all cancer treatments have had such dramatic improvements on life expectancy, and some drugs may not be worth the cost. However, when the cost of innovative drugs is viewed over their branded and generic lifetime, it seems 1802

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that a good deal is being obtained for the cancer dollars expended, with substantial increases in survival at reasonable cost. So why the uproar about cancer in particular? Many health care services have higher costs than oncology drugs—the cost of a stay in the intensive care unit (ICU) is about $20,00018—or provide little value for the money, such as magnetic resonance images (MRIs) for sprained ankles.19 Yet one does not see such handwringing about ICU costs or MRIs because payers and providers have deemed those costs to be acceptable and appropriately allocated. In fact, the outrage arises because it is the patient, not the insurer, who has to pay. Among specialty drugs, cancer drugs have the highest out-of-pocket spending burden imposed on patients.20 Patients may be asked to pay 50 percent of the cost of newer cancer drugs out of pocket,21 compared with a much smaller fraction of the cost of an ICU stay. This financial burden can be “devastating,” according to leading oncologists.2 Clearly reimbursement for treatments that have little or no health benefit should be challenged. However, blanket policies that shift the cost burden onto a subset of patients with rare or difficult-to-treat cancers—or that lower all prices together—would discourage future innovation and deprive patients of novel therapies.

Myth 4: Cancer Treatment At The End Of Life Is Of Low Value This myth arises from a fundamental misconception about the value of care delivered to the terminally ill.22 More specifically, policy makers assume that the value of a life-year remains constant, regardless of a patient’s circumstances. Evidence—and consumer behavior—would suggest otherwise. An anecdote is helpful. In 2008 the New York Times published a story on Avastin, a drug that inhibits the growth of new blood vessels, emphasizing the dilemma posed by its modest improvement in survival rates and high cost. A few days later, reader Jana Jett Loeb wrote a Letter to the Editor, poignantly explaining the value of Avastin to treat her father’s glioblastoma off-label: “The hope this drug provides our family is just as important to prolonging my father’s life as the drug itself.”23 As Loeb makes clear, there is additional value in treatments that give people hope, despite modest survival benefit. One study estimated that patients with metastatic disease value treatment at levels twenty-three times higher than the cost of the therapy.24 It is also known that median survival does not capture the right-tail chance of success often associated with the hope of full

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only 3 percent of the increase in all cancer survival.4 Furthermore, better detection has no value if effective treatment is not available. A diagnosis of multiple myeloma in the 1960s meant a median survival rate of less than one year,10 compared to more than six years today.11 Patients diagnosed with metastatic colorectal cancer could expect an eight-month median overall survival rate two decades ago, compared to thirty months today.12 These make detection far more valuable. Thus, perhaps ironically, the best way to encourage more screening may be to identify better, earlier-stage treatments.

Myth 5: Supportive Care Is Overused Many of the most effective cancer treatments have significant side effects, including pain, nausea, fatigue, anemia, and susceptibility to infection. Supportive care therapies, such as colony stimulating factors and anti-emetics, address one or more of these side effects. Nevertheless, many view them as a cost with little benefit.22 In reality, supportive care enables the administration of more aggressive chemotherapy regimens by avoiding or managing the debilitating effects of the toxicity. Aggressive regimens, facilitated by supportive care, slow disease progression and improve overall survival. Indeed, some of the best clinical trials include supportive care as part of the protocols.28 However, the incidence of neutropenia and the use of supportive care therapies are underreported in clinical trial publications, underrepresenting the value to society of supportive care.29,30 As treatments evolve over time, supportive care regimens will remain an integral part of innovation and patient care.

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Preferred hopeful therapy A recent study found that 77 percent of cancer patients with melanoma preferred hopeful therapies and were willing to pay $54,000.

Conclusion Cancer has always been the “Emperor of All Maladies.”31 But any illness with such a majestic designation is bound to be surrounded by myths, many of which arose years ago when the illness was much less understood. The reality of cancer today is of a disease far more nuanced, reflecting systematic progress in treating the disease. New paradigms have led to the development of groundbreaking biologic therapies, with a lower risk of adverse events and side effects—but also with a commensurate cost. It is now known that cancer is actually hundreds of diseases, many of which are rare. Scientific discovery will likely not allow for the development of “common cancer” treatments that will be effective in all cases. Rather, identified cancer subtypes that can be targeted by drugs are ultimately costly to develop, particularly when the treated population is small. Coverage policies that place undue burden on patients may discourage further innovation of treatments targeting rare genetic mutations and tumor subtypes. The call to artificially lower drug prices may address immediate affordability problems but—if done incorrectly—will come at too high a cost for future cancer patients’ health. ▪

Support for this research was provided by Amgen. Technical and administrative support was provided by Jacquelyn Chou and Joanna P. MacEwan.

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remission. As a result, coverage decisions based solely on median survival will neglect the great social value for a minority who live long after the trial ends. This does not mean that insurers should cover all hopeful therapies in the absence of clinical evidence. However, it does mean that the way in which trial results are evaluated should be reconsidered. A recent study demonstrated that 77 percent of cancer patients with melanoma preferred hopeful therapies, even with uncertainty as to where they would fall on the survival curve, and were willing to pay over $54,000 for a hypothetical treatment with the same median survival but a better chance at long-term survival.25 Second, behavior demonstrates that life is more precious when less of it remains. Ordinary people recognize this point, but current qualityof-life metrics do not.While patients often refuse to take their ordinary medications when copayments increase just a few dollars, cancer drugs are different. Patients are willing to pay substantial amounts out-of-pocket, indicating tremendous consumer value.20,24 Third, society as a whole places higher value on treatments for those who are sicker. Surveys show that people are reluctant to forgo care for the elderly, even if resources devoted to that care could more effectively improve population health if used elsewhere.26 The same survey suggests that people would rather society choose interventions that make the lives of a few much better off than interventions that make the lives of many only slightly better off. In the United Kingdom, growing complaints about denials of effective but costly treatments for life-threatening diseases have prompted a compassionate care exception to the cost-effectiveness threshold for patients with poor prognoses. Finally, recent evidence suggests that healthy people are willing to pay higher premiums for access to treatments analysts often deem of no value. By some estimates, adults in the United States are willing to pay on average an extra $2.60 in insurance premiums for every dollar of cancer drug coverage.27 Bottom line, the QALY-based approach to decide necessity is inconsistent with patients’ and society’s value of cancer care.

Cancer Care NOTES

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