Speakers here at the Association of American Cancer Institutes (AACI)/Cancer Center Administrators Forum Annual Meeting discussed the escalating costs of cancer care and what can be done to keep high-quality care affordable. According to a new report on the crisis in cancer care from the Institute of Medicine (OT 10/10/13), the cost of cancer care is rising much faster than that of other sectors of medicine. It is expected to rise from $125 billion in 2010 to $173 billion by 2020, a 39 percent increase. In 2004, that cost figure was $72 billion.
Trying to put the cost crisis in perspective, Lee N. Newcomer, MD, MHA, Senior Vice President of UnitedHealthcare, said that balancing the needs of one cancer patient against the needs of many is a major challenge for insurers. He noted, for example, that one course of treatment with ipilimumab for one metastatic melanoma patient (perhaps gaining that patient an additional year of life) can cost $1.6 million—a sum that can provide health insurance for 100 families for one year.
“What keeps me awake at night is that things are moving too fast … precision medicine is moving too quickly,“ said Newcomer of targeted new drugs in cancer care. “There is a presumption that a ‘druggable’ target works for all cancers at all times. Where is the evidence? When the evidence is there, we [insurers] will be there as well. We’re in a tough spot—right now we’re moving way ahead of the evidence, and we cannot afford to do so. We tend in oncology to leap ahead of the science.”
He said that in addition to the need for more hard evidence on the effectiveness of targeted therapies, oncologists need to look carefully at the cost consequences of where cancer therapy is delivered. Citing the treatment shift from community oncologists to hospital clinics, he said, “No therapy should cost more simply because it is given in a different location.”
Asked by OT about Newcomer’s comments, AACI President Michelle M. LeBeau, PhD, said, “I think he raises good points. I think we do need good clinical trials.” But LeBeau, Director of the University of Chicago Comprehensive Cancer Center, defended the role of cancer centers in delivering cutting-edge therapy, noting that the standard of care is established in these academic centers.
Brian J. Druker, MD, Director of the Knight Cancer Institute at Oregon Health and Science University, said that accelerating research is the ultimate answer to the rising costs of cancer care because it holds the promise of not only earlier detection, but also prevention.
Druker, who received AACI’s Distinguished Scientist Award at the meeting and whose laboratory was instrumental in the development of imatinib for chronic myeloid leukemia (CML), said that diagnosing cancer earlier and combining targeted therapy with chemotherapy “dramatically improves outcomes.” He said, “We have to move rapidly to combination therapies and we have to collaborate,” adding, “We have a big task ahead of us—we have to identify the molecular pathogenetic mutations in all cancers.”
In an interview, Druker elaborated on his views on earlier detection and cancer prevention, both of which have the potential to bring down the costs of care. “We don’t want to be treating advanced cancers; we really don’t.” Looking ahead to the future of cancer care, he said he envisioned giving women at very high risk of breast cancer (because of BRCA1 or BRCA2 mutations, for example) a choice: radical prophylactic surgery to remove their breasts or a preventive, well-tolerated drug to lower their risk.
In years to come, he predicted, when people’s genetic risk factors can be delineated, preventive therapies based on their cancer risk-factor profiles will be possible. Asked if preventive approaches in cardiology are a good analogy to what he envisions for oncology, Druker said yes. In cardiology, he noted, people with high blood pressure are put on hypertension-lowering drugs routinely, and those with high cholesterol are routinely prescribed cholesterol-lowering drugs such as statins.
During a panel session on the costs of cancer care, the moderator Ellen V. Sigal, PhD, Chairperson and Founder of Friends of Cancer Research, called the current landscape for cancer patients “the best of times and the worst of times.” The best, she said, is that “the science has never been better.” The worst, though, is “the dysfunction in Washington, the sequester, and the fact that there just is no money.”
Peter Bach, MD, MAPP, Director of the Center for Health Policy and Outcomes, Epidemiology and Biostatics Department at Memorial Sloan-Kettering Cancer Center, said that in such times, during which rising spending is “pushing health care to the brink,” there are specific strategies that can be used to contain costs.
As one example of such a strategy, he named alternative reimbursement methods to physicians, specifically:
- Episode-based payment, which is a bundled sum for the management of a disease episode;
- Payment based on adherence to pathways—i.e., following evidence-based guidelines; and
- Competitive acquisition of outpatient drugs and biologicals.
The current system, Bach noted, makes more expensive drugs more profitable. He agreed with Newcomer that it is much cheaper to give care in the community than in the hospital.