Blog | Monday, July 11, 2011

Running two lists that might lessen the costs of oncology care


Recently the New England Journal of Medicine ran a Sounding Board piece on Bending the Cost Curve in Cancer Care. The authors' take on this problem: "Annual direct costs for cancer care are projected to rise--from $104 billion in 2006 to over $173 billion in 2020 and beyond. ... Medical oncologists directly or indirectly control or influence the majority of cancer care costs, including the use and choice of drugs, the types of supportive care, the frequency of imaging, and the number and extent of hospitalizations ..."

The article responds, in part, to Dr. Howard Brody’s 2010 proposal that each medical specialty society find five ways to reduce waste in health care. The authors, from the Divisions of Hematology-Oncology and Palliative Care at Virginia Commonwealth University in Richmond VA, offer two lists:

Suggested Changes in Oncologists’ Behavior (from the paper, verbatim — Table 1):
1. Target surveillance testing or imaging to situations in which a benefit has been shown.
2. Limit second-line and third-line treatment for metastatic cancer to sequential monotherapies for most solid tumors.
3. Limit chemotherapy to patients with good performance status, with an exception for highly responsive disease.
4. Replace the routine use of white-cell-stimulating factors with a reduction in the chemotherapy dose in metastatic solid cancer.
5. For patients who are not responding to three consecutive regimens, limit further chemotherapy to clinical trials.

Suggested Changes in Attitudes and Practice (same, Table 2):
1. Oncologists need to recognize that the costs of cancer care are driven by what we do and what we do not do.
2. Both doctors and patients need to have more realistic expectations.
3. Realign compensation to value cognitive services, rather than chemotherapy, more highly.
4. Better integrate palliative care into usual oncology care (concurrent care).
5. The need for cost-effectiveness analysis and for some limits on care must be accepted.

For today, I’ll leave this provocative list without comment except to say that it should engender some long and meaningful, even helpful discussion.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.