By Lee N. Newcomer

VIEWPOINT

Myths And Realities In Cancer Care: Another Point Of View

ABSTRACT Cancer care is advancing, and the cancer community is right to celebrate that progress. Simultaneously, however, the cost of cancer therapy is rising along with all medical costs. In a matter of just a few years, the cost of health coverage is projected to reach heights that are simply unsustainable for most American families, overshadowing every other daily expense. Such an overwhelming burden will continue to undermine the progress made in developing new, more effective treatment and care for cancer patients. There cannot be a celebration of discoveries if there is no way to pay for them. It is from that perspective that I react and respond here to the commentary of Dana Goldman and Tomas Philipson, who debunk five myths in cancer care. I concur with the authors’ assessment of the value and impact of progress in cancer care. However, I also argue that researchers and policy makers must pay more attention to the impact of cost on patients’ adherence and experience and the speed with which new treatment and care are being developed.

B ased on current trends, econo- mists predict that in less than three years a family’s typical health in- surance premium and out-of-pock- et costs will equal 50 percent of the

average US-household income.1 The same study notes that fourteen years later the cost of health care coverage will equal 100 percent of house- hold income. As costs continue to rise, health care providers and researchers must discover methods to reduce the cost of care while advanc- ing the progress that has beenmade against can- cer. In this commentary I take the same five myths that Dana Goldman and Tomas Philipson have sought to debunk2 and, in reverse order, offer additional considerations that policy mak- ers should take into account.

Myth 5: Supportive Care Is Overused Goldman and Philipson are correct: It is a myth that supportive care is overused. However, sup-

portive care is undermined bymisuse. A study of 1,849 lung and colon cancer patients treated at multiple centers demonstrated underuse of sup- portive care,withonly 17percent of patientswith high-risk chemotherapy regimens receiving granulocyte colony stimulating factors (G-CSFs) to prevent low blood counts.4 The same study also showed significant overuse. Overall, for thesepatients, 97percentof theG-CSFs thatwere administered were not recommended by evi- dence-based guidelines. Palliative care offers one pathway to the dis-

cussions of patient goals that are critical for as- suring the appropriate use of supportive care. A trial of all lung cancer patients in an academic oncology clinic randomized patients to standard oncology careor to standardoncology carewitha palliative care consultation. The palliative care group had better quality-of-life scores, lived 2.7 months longer, used less chemotherapy, and had less aggressive end-of-life care.4 The palliative care patients established clear goals

doi: 10.1377/hlthaff.2014.0893 HEALTH AFFAIRS 33, NO. 10 (2014): 1805–1807 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.

Lee N. Newcomer (lee_ newcomer@uhc.com) is senior vice president in Oncology Services at UnitedHealthcare, in Edina, Minnesota.

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Cancer Care

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for their therapy at the beginning of treatment. Without that vital discussion, assigning value to supportive care is either flawed or impossible.

Myth 4: Cancer Treatment At The End Of Life Is Of Low Value Goldman and Philipson argue that patients are willing to pay more for hopeful therapy—espe- cially for cancer treatments. The papers support- ing this assertion use hypothetical estimates of a patient’s willingness to pay. Yet real-world data suggest that patients are lesswilling to reach into their own pockets for cancer therapies with lim- ited values. An analysis of a large payer data set examined the compliance of oncology patients with specialty pharmacy support—including twenty-four-hour access to oncology pharma- cists for side-effectmanagement and compliance encouragement—compared tooncologypatients with less comprehensive support from retail pharmacies. Each group paid a $50 copayment for drugs costing about $5,000 per prescription. Themean possession ratio, ameasure of compli- ance based onprescription filled, was 66 percent in the specialty pharmacy group and 58 percent in the retail group.5 Presumably, the additional support enjoyed by the first group eliminated medical reasons for noncompliance, explaining its 12 percent higher rate of compliance. The remaining 34 percent rate of noncompliance is, therefore, probably the effect of cost. If $50 keeps a patient from purchasing an oncology drug at the end of life, it is hard to believe the melanoma study6 cited by Goldman and Philipson showing that patients are willing to pay $54,000 for a hypothetical treatment. The difference between these two studies is that one highlights patients’ willingness to spend their own money, and the other shows patients’ will- ingness to spend someone else’s money.

Myth 3: Treatment Costs Are Unsustainable As already stated, the US health care system can- not continue to spend at its current trend. The average household cannot be expected to spend its entire income on health care. Because of their high prices, new drugs are attracting the most attention, but cancer therapy involvesmore than just drugs. Chemotherapy drugs represent 24 percent of total care costs, inpatient and out- patient facility services account for 54 percent, and physician services constitute the remaining 22 percent of total costs for commercially in- sured cancer patients at UnitedHealthcare.7 A recent study demonstrated that by finding sav- ings elsewhere, five medical oncology groups

could reduce the total cost of cancer care by 34 percent in a cohort of 810 patients, even as they increased cancer drug spending by 179 percent.7

Cancer patients are widely portrayed by pa- tient advocates as having an extraordinary finan- cial burden for their illness. Goldman and Philipson, for example, cite examples of patients paying 50 percent of the cost of newer cancer agents.8 But that is not always the case. Such enormous out-of-pocket expenses are typically associated with low-cost insurance that offers fewer benefits. Patients in these frequently cited examples are almost always takinghigh-cost oral cancer medications or other specialty medica- tions like them—such as treatment of multiple sclerosis, for example—under low-premium pharmacy plans. Higher-premium plans offer more reasonable patient cost sharing such as the $50 copayment example described earlier. Furthermore, most oncology drugs are given un- der the medical benefit of an insurance plan, in which drugs are usually subject to the same cov- erage benefits as the intensive care unit visit mentioned by Goldman and Philipson. Under the medical benefit, out-of-pocket expenses are almost always capped, and once the cap is met, claims are covered completely. Members who purchase insurance with good benefits will pay a higher premium, but their coverage will make their individual cost sustainable. I agree with many of the points made by

Goldman and Philipson debunking Myth 3 that treatment costs are unsustainable. First, treat- ments that have little or no health benefit should be challenged for reimbursement. Second, can- cer patients should not bear more burden than other severely ill patients simply because they have cancer. Hospitals often use this tactic when they purchase oncology practices: On average, according to internal UnitedHealthcare data, medical oncologists in private practice are paid 22 percent more thanMedicare rates for provid- ing chemotherapy. However, hospitals that own oncology practices or employ medical oncolo- gists can use their contracting leverage to earn reimbursement for the same service at an aver- age of 146 percent more than Medicare, also according to internal UnitedHealthcare data. It is not right that cancer patients are bearing this heavier burden.

Myth 2: Detection, Not Treatment, Accounts For Most Of The Survival Gains As Goldman and Philipson argue, the number of adult cancers with significant improvement in survival due to treatment breakthroughs is im-

Cancer Care

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pressive; breast cancer, colon cancer, multiple myeloma, and chronic myelogenous leukemia are good examples. Even more impressive is theprogress inpediatric cancer largely as a result of rigorous enrollment of nearly every child into clinical trials. In stark contrast, only about 3 per- cent of adult cancer patients are enrolled in clin- ical trials. The USmedical care system ismissing a great opportunity to quickly learn about new therapies. Enrolling more adults in cancer clini- cal trials will accelerate the pace of new cancer drug approvals. Unfortunately, the number of trials being of-

fered is diminishing because of decreased fund- ing and lengthy approval processes. But many organizations have begun to take new ap- proaches. The lung cancer master protocol, the Multiple Myeloma Research Foundation, and the I-SPY adaptive breast cancer trials have shown what is possible when the principles of collaboration, speed, and access are given prior- ity. These programs are proof that the US re- search system can improve its performance.

Myth 1: The War On Cancer Has Been A Failure The term “failure” is relative and, I agree with Goldman and Philipson, misguided. When one

compares the improvement in survival with heart disease versus cancer—the nation’s two largest killers—it is clear that cardiac survival has improved far more than cancer survival.9

More importantly, both diseases are causing less mortality. To use the metaphor of war, many battles have been won in cancer, but the theater of operations is much larger because there are scores of cancer types. Progress, even at a slower rate, is not failure. Researchers, patient advocates, and policy

makers should, nevertheless, push harder to im- prove the rate of progress. Finding ways tomake cancer care affordablemust be an important part of that effort.

Conclusion A myth is a story, usually without basis in fact, that one tells to explain some practice or event. As Goldman and Philipson have shown, solid facts demonstrate that the cancer community is producing better treatments and outcomes. Yet these advances, though encouraging, can be better. The same cancer community that has achieved such important progress still faces another big challenge: to produce these treat- ments faster and for less cost. ▪

NOTES

1 Young RA, DeVoe JE. Who will have health insurance in the future? An updated projection. Am Fam Med. 2012;10(12):156–62.

2 Goldman DP, Philipson T. Five myths about cancer care in America. Health Aff (Millwood). 2014;33 (10):1801–04.

3 Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small- cell lung cancer. N Engl J Med. 2010;363(8):733–42.

4 Potosky AL, Malin JL, Kim B, Chrischilles EA, Makgoeng SB, Howlander N, et al. Use of colony-

stimulating factors with chemother- apy: opportunities for cost savings and improved outcomes. J Natl Cancer Inst. 2011;103(12):979–82.

5 Tschida SJ, Aslam S, Lal LS, Khan TT, Shrank WH, Bhattarai GR, et al. Outcomes of a specialty pharmacy program for oral oncology medica- tions. Am J Pharm Benefits. 2012; 4(4):165–74.

6 Lakdawalla DN, Romley JA, Sanchez Y, Maclean JR, Penrod JR, Philipson T. How cancer patients value hope and the implications for cost-effec- tiveness assessments of high-cost cancer therapies. Health Aff (Mill- wood). 2012;31(4):676–82.

7 Newcomer LN, Gould B, Page RD, Donelan SA, Perkins M. Changing physician incentives for affordable, quality cancer care: results of an episode payment model. J Oncol Pract. 2014 Jul. [Epub ahead of print].

8 Fenn KM, Evans SB, McCorkle R, DiGiovanna MP, Pustzai L, Sanft T, et al. Impact of financial burden of cancer on survivors’ quality of life. J Oncol Pract. 2014 May. [Epub ahead of print].

9 Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. National Vital Statistics Reports. 2013;61(4): 1–17.

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3% Enrolled in trials Only about 3 percent of adult cancer patients are enrolled in clinical trials; in contrast, nearly every child cancer patient is enrolled in a trial.

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