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A woman holds the hand of her mother who has cancer.

A cancer patient is comforted by her daughter in a hospice facility.

PHOTOGRAPH BY SEAN BEST, REUTERS

Cathy Newman

National Geographic

Published February 14, 2014

The malady of rising medical costs is acute, especially in the field of oncology. As populations age, new cancer cases are expected to reach 21.4 million in 2030, while treatment costs are projected to increase 40 percent by 2020.

Is there a remedy? In the February 14 issue of the Lancet Oncology, doctors Ronan J. Kelly and Thomas J. Smith of the Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins Medical Institutions in Baltimore suggest that costs can be contained without increasing risk to patients. We spoke with Dr. Smith.

The United States spends twice what any other developed country does on health care: $2.7 trillion a year. Oncology has the fastest rate of increase in treatment costs. Even so, I would imagine the instinct of any patient faced with a cancer diagnosis would be: "Spare no expense." Isn't talk of cost reduction a charged subject?

It shouldn't be if we are all in this together. Whether we admit to that or not is another matter.

What role does the oncologist play in this issue?

Oncologists tend to think someone else is responsible for the costs and that we don't have the ability to make an impact. I believe we can. We point out some practical things that can be done.

Let's look at the first area of possible improvement you target: hospitalization costs.

A paper by Nancy Morden and colleagues at Dartmouth looked at patients with a poor medical prognosis and found that only 54 percent were touched by hospice. This says to me that we as oncologists can do better.

That speaks to the difficult conversation that doctors often avoid when addressing a patient with an incurable disease.

You have to say to the patient: "We'll give you the best opportunity to live as long as and as well as you can. But if the cancer returns, we need to realize there will be a time when chemo won't help."

Which is when, you indicate, the conversation should turn to hospice care. In your paper you state that hospice care provides better care and quality of life at a lower cost than hospitalization. The alternative is what?

An expensive hospital stay that the patient might not need or want. The hospital is not where most people want to die.

Next is the expense of medical imaging.

The use of PET scans has gone up by an amazing amount. PET scans are good to look at. They give what you might think is better information. But it hasn't been shown, except in rare instances, to be an essential part of treatment. A PET scan costs between five and ten thousand dollars. A CAT scan is two thousand dollars max. In one very good study, lymphoma patients followed by PET scans did not have better results than those followed by physical exam or CAT scans.

Finally, you discuss the cost of cancer drugs.

This is the part where oncologists have the least impact. We are bystanders like everyone else.

What can be done?

We argue that the FDA, Medicare, insurance companies, the public, and the pharmaceutical companies have to come to some agreement. Competitive bidding by hospitals and health systems should be used to drive prices lower. We are sympathetic to drug companies that want to charge enough to generate enough return of the cost of investigation, but we need transparency regarding the cost of development. Some drugs can cost a billion to develop, perhaps, but not every one. There has to be some way to relate the price of the drug to the value of the drug. And we have to set limits.

And if we don't?

We'll get to a situation where only the richest of the rich can afford these drugs, and we will have a lot of people looking on from the sidelines.

5 comments
Peter Stone
Peter Stone

Why on earth is Hyperbaric Oxygen Therapy overlooked? It gives the body its own fighting chance and the likelihood that all other treatments regimes will benefit and do a much better job of ridding the body of this terrible dis-ease.

MARGIE JOHNSTON
MARGIE JOHNSTON

I am in a third battle with breast cancer, Stage 4.  The other two times I was treated with conventional chemo, I thought very successfully.  Now my oncologist is treating me with the chemo drug Faslodex.  This is an injection once per month after the initial load month.  This injection is 500 mgs and the cost is $3700 + per injection.  I know that this drug in essence is starving the cancer, and I will be on it the rest of my life.  However, to imagine that the cost could not somehow be reduced is beyond my comprehension.  At this cost, the R&D should have been covered a very long time ago, which should then enable the manufacturer to reduce it to some more reasonable level. 

John Patt
John Patt

I am dismayed that all we ever hear about is "finding a cure for cancer." There seems to be very little effort in finding the cause of cancer, which would prevent the patient not only from the exorbitant expenses, but also from having to suffer through this dreaded disease. Cancer is caused basically by uncontrolled mitosis, something that is covered in high school biology. It's hard to imagine that we cannot make some serious inroads into this problem with our increasing knowledge of genetics and biochemistry.

The pharmaceutical companies have little incentive here, but the public sure does.

John H.
John H.

You are correct. The cost of your chemo drug could easily be reduced to an affordable level if the manufacturer of your drug chose to do so. Two of the reasons that this is not likely to happen are: 1. Drug companies are beholding to their investors, who are more interested in profits than humanitarian care.. If the drug companies were to prioritize cancer patients interests over the interests of their investors, they would soon be out of business. 2. Lack of competition. The drug companies hold patents on their proprietary drugs. No other company can legally produce and market those drugs.

For example: Aspirin can be manufactured and marketed by any drug company, and most do, because the patent rights have expired long ago. This is why you can buy it over the counter for $0.99 per bottle of 100 or more. Without competition, there is no incentive to lower prices.

Oh, but in a perfect world. Until then, you need to buy better insurance.

How's "The Affordable Care Act" working for you?

John H.
John H.

I couldn't agree with you more. In my 67 years on this planet, I have lost four family members from cancer and I myself am a cancer survivor. That I survived is pure luck. Mine was kidney cancer, which was discovered while I was having an ultrasound for an unrelated problem. Fortunately, there was no metastasis, and the kidney was removed.

The problem, as I see it, is there is too much money invested and to be made in the current standard of care, for the industry to be willing to switch to a prevention oriented solution.

Whenever new therapies are introduced for the treatment of cancer, the FDA and Big Pharma, will do anything to discredit them, to serve there own self interest. That being, their investor based profit picture.

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