The health care reform act – known as the Affordable Care Act, passed by Congress and signed into law last year after much contentious debate – will have a profound effect on health care in the United States if it survives the numerous legal challenges making their way through the courts. What are the likely effects on cancer care? Is there going to be rationing of health care in general, and cancer care in particular?
There is a commitment in the legislation to look at what works, i.e., how real-world outcomes should drive health-care decisions. How does this effect cancer care?
What follows are some of my editorial comments on how health-care reform and cancer care might intersect, especially over cost-effectiveness. They do not reflect the policies of Bon Secours Hampton Roads.
Above all, cancer care must work. My national society, the American Society of Clinical Oncology, has issued numerous position papers on this point. Ineffective treatments must be discarded. Remaining is the controversy of how much improvement in outcome is required to justify the extraordinary cost of modern drugs and procedures.
For example: the drug Tarveca has been approved as an addition to best available therapy for advanced incurable cancer of the pancreas. Tarceva at the dose used in pancreatic cancer retails for almost $5000/month. The net survival benefit for patients who receive this drug in addition to other best therapy is about ten days of additional life: 5.9 vs. 6.2 months (see J. Clin. Oncol 25 (28) 4506-7, 2007 for a scholarly discussion of this issue). Patients need to be on this drug for several months before it is clear whether it is even working.
Do the math: If you are on this drug for four months, the cost per day of additional survival is $2000. This is extraordinary by any economic standard. What is lost in the discussion is the occasional patient whose life is prolonged for months, not days, by this drug. I have one such patient in my practice. In outcomes statistical language this patient is an outlier. However, he is grateful.
Would it be tantamount to rationing to deny payment for a drug which costs $2000/day of additional life? I believe the answer is yes, but from a public policy perspective this might not be a bad thing given that resources are finite. Physicians, however, should not, in my opinion, make decisions based on cost to the “system.” Their entire responsibility ethically is to the patient, not the system. Public policy needs to address the issue of how much care is too much care with respect to what the system can afford, not the physician. Otherwise the doctor would have an intolerable conflict of interest.
This editorial is not meant to demonize one particular drug; however, can society afford Tarceva for pancreatic cancer? Is it ethical even to have this discussion? Some politicians demagogue the issue by referring to outcomes analysis as “death panels.” What we need is calm, rational discussion about what we as a society can afford, not demagoguery. I do not have an easy answer to these questions.
Tarceva for pancreatic cancer is the tip of the oncologic iceberg. I could cite a dozen comparable examples. Who should decide what a life, or a few months of life, is worth? Surely not the United States Congress, whose members get health care for free and are largely out of touch with real people. I invite my readers to comment below and begin anew a dialogue on this vexing problem, for it is our problem to solve.