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.