News

In the New England Journal of Medicine on May 26, 2011, Thomas Smith and Bruce Hillner describe a series of strategies to reduce the cost of spending on cancer care in the United States. The article is compelling, and highlights the reasons health care spending is so difficult to talk about—much less do something about: all five strategies involve changes to attitudes and practice that are both fundamental to making a difference—and extremely difficult to accomplish.

Cancer care is an important area to examine, not only for its impact on health care spending but also because of its human dimension. Despite progress on many fronts clinically, cancer continues to be a disease that strikes fear into most. Individuals and families face difficult choices balancing the risks and benefits of treatments, many of which have toxic side effects that can interfere with the quality of life. Oncologists and other treating practitioners must take into account the very human desire to have hope, along with the reality of the prognosis and availability of effective treatments.

Spending on cancer care is no small issue. In 2006, direct cancer costs were $104 billion and are continuing to rise. With genetic breakthroughs, new therapies continue to be developed and the costs associated with many of these new therapies are astronomical. Some treatments have scant evidence of positive impacts on quality of life or longevity but nevertheless are promoted as offering hope—sometimes the only hope left for survival.

What do Smith and Hillner recommend? They hit all the big points: different approaches to screening, more judicious approaches to treatment choices, changes in compensation, and a greater willingness to confront the realities and speak honestly with patients about prognosis and treatment choices.

For example, they note that surveillance testing or imaging does not change outcomes for most cancers—including pancreas, ovary, lung and breast—yet these approaches are commonly used. In a 20-year old study of breast cancer, scheduled imaging (not symptom related) was not shown to detect curable recurrences or alter survival rates—yet more a $1 billion per year was spent on these tests.

Smith and Hillner also suggest limiting treatment strategies, both to better comport with the evidence of what works to impact survival or quality of life, and based on the functional status of the patient. They advocate for more data on comparative effectiveness and a willingness to make treatments choices by weighing cost with the potential for benefit—a position that has been demagogued by some as a plan to kill off patients.

As part of these changes, the authors also recommend that palliative care be provided earlier and more extensively than happens today. They understand that choices must be made regarding which (and whether) treatment is to be provided, and that sometimes, it may be better to focus on comfort and quality of life rather than extending life. Being able to make these kinds of choices is fundamental to our ability to make changes in the quality of life in a patient’s last days, as well as the cost picture for cancer (and all other medical care).

These are difficult conversations for both physicians and patients. Smith and Hillner cite a study that indicates that most patients with lung cancer expect to live two years, when the actual average life expectancy with this diagnosis is six months.

Having these kinds of conversations requires not only oncologists willing to be clearer about prognosis and patients open to hearing it, but also a change in our reimbursement systems to compensate providers for these kinds of discussions. Today, our reimbursement system for all practitioners focuses heavily on providing more compensation for doing things—procedures, drugs and the like—and not enough for the talking and coordinating aspects of care that are essential to the transformation of the health system.

The Smith and Hillner’s recommendations focus on patients with incurable solid tumors. In these cases, it would seem that some limits on care might be easier to accept. But it is precisely because many Americans—patients and doctors alike—are unwilling to accept the concept of “incurable” that these changes are so difficult to make.

Honest conversations about the limits of medicine will be crucial if we are really going to change the trajectory of spending and interventions in which we are so enmeshed today.