Last week I published a column on this blog regarding the thorny issue of how we as a society could approach the issue of affordable cancer care, and which treatments might simply be unaffordable from a societal perspective.
Shortly after this blog was posted the world’s leading medical journal, the New England Journal of Medicine, weighed in with an editorial by two physicians from Virginia Commonwealth University on the same subject. Drs. Thomas Smith and Bruce Hillner have suggested guidelines by which oncologists can judge whether it is justified to continue to offer patients very expensive treatments which in many cases have a very limited chance of success. Those guidelines suggest among other things stopping chemotherapy after three different treatment regimens for patients with the most common cancers, and lowering the chemo doses to prevent toxic (and expensive) side effects if cure is not possible.
Another interesting discussion, not touched upon in my earlier blog, was the recommendation about diagnostic testing. What tests should be done for patients who have been treated for cancer to see whether the cancer is coming back? The bias of the editorial was that doctors order too many diagnostic tests, that in many cases the results of the test cannot provide any information which would prolong life. Many patients are comforted by knowing that blood tests or imaging studies show no evidence of recurrence, but is this sufficient reason to do the tests, especially when their sensitivity (ability to pick up early recurrence) is severely limited? The American Society of Clinical Oncology and the National Comprehensive Cancer Network have strongly discouraged oncologists from ordering routine testing when patients are asymptomatic and when finding early recurrence will not alter outcome. Only for colon cancer are there any data (and they are not robust) that routine surveillance lab work and imaging studies have any impact on prognosis. I believe that most oncologists know this and that it is primary-care physicians and surgeons who over-order tests, but there are no data on this point. One estimate puts the annual cost of information so gleaned at over $1 billion. In the totality of health-care costs this is not that large a figure, but when you add in additional testing necessitated by the original abnormal finding, the number must be much higher – all to no avail!
Underlying all of this discussion is a rational approach to dealing the expectations of patients are their families. Oncologists are notoriously overly optimistic when explaining new therapies to patients. A large dose of reality could go a long way toward curbing unnecessary testing and therapy. Smith and Hillner argue for earlier referral for hospice and palliative care as a way towards alleviating patient suffering and lowering cost.
Inevitably in an era of skyrocketing health-care costs and an expanding older population, cost containment will come up. It is arguably the job of the Oncology community to chart a responsible course for itself and its patients or one will be forced upon them.