Health care leaders and economic analysts predict that by 2021, nearly 20 percent of the U.S. gross national product will be spent on health care spending. The growing cost of cancer care will increase from$12.5 billion in 2010 to$17.3 billion in 2020. Therefore, the goal of future efforts is to control costs while also ensuring high quality care. A symposium titled “Providing Affordable Cancer Care in the 21st Century” was held in October 2012, sponsored by the National Cancer Policy Forum of the Washington Medical Association. At the meeting, experts presented the need to use new and existing tests, treatments, and protocols in a rational, evidence-based, and value-based perspective. Proceedings and images from the meeting have been summarized in the fall issue of the Journal of Clinical Oncology, and attendees included bio-theoretical scholars, economists, and primary care physicians, as well as medical, surgical, and radiation oncologists. Three areas were discussed: 1) cancer screening; 2) cancer treatment, including systemic therapy and radiation therapy, and surgery; and 3) supportive care. The presenters’ representative, Ya-Chen Tina Shih, an economist and professor at the University of Chicago School of Medicine in Illinois, said the symposium helps raise awareness of the high cost of cancer care and possible cost-driven orientation, and also helps inform the public that the issue of affordable cancer care is a focal point of the entire cancer care process. The workshop can provide information on the number of care interventions that are being delivered or payment mechanisms that may reduce costs without compromising quality. In addition, it provides background information for the recently released IOM (Institute of Medicine) report, entitled “Delivering Quality Cancer Care: Charting the Course of a New Crisis System,” Dr. Shih said. Cancer Screening In the report, Dr. Shih and her team begin by presenting practice approaches to cancer screening, including prostate antigen (PSA)-based prostate cancer screening, colonoscopy, and mammography, which are overused or inappropriately used, and which are underused in some populations. For example, they cite 2 randomized controlled trials and several observational studies that found little to no effect of PSA testing on prostate cancer mortality, while nearly twice as many men were diagnosed and treated for prostate cancer. The authors note that despite the evidence from clinical trials, the use of PSA screening was only mildly reduced. Dr. Otis Brawley, who is medical director of the American Cancer Society (ACS) and co-author of the report, said the ACS and five other organizations, including the American Urological Association, recommend that men should be informed of the potential benefits and risks of prostate cancer screening and encouraged to choose whether to have the test. “Many internists and patients are unaware that there are no reputable medical institutions that have been fully implementing prostate cancer screening for more than a decade,” Dr. Brawley said. Similarly, the authors point out that the routine method of breast cancer screening, mammography, has resulted in overdiagnosis. Although breast cancer mortality has been shown to decline by 20-30 percent in women aged 50-69 years. However, this benefit was found only after 7 years of mammography screening. Therefore, screening women with a life expectancy shorter than 7 years does not reduce their chances of dying from breast cancer. Nevertheless, these screenings are still widely used in women with shorter life expectancies. Similarly, transvaginal ultrasound to screen for cervical cancer and chest radiography to screen for lung cancer are not supported by scientific data but are also widely used. Among older adults, colonoscopy has proven to be overused, with one study showing that nearly a quarter of patients underwent colonoscopy within 7 years (from the most recent examination, without any clinical need, but the guideline-recommended interval between examinations is 10 years. However, underutilization of cancer screening also exists at the same time. In several populations, including those lacking education, uninsured, and of lower socioeconomic status, there is a lack of adequate mammography, Pap smears, and colonoscopy screening, the authors noted. Inappropriate screening tests may result in overdiagnosis and overtreatment, the latter of which comes with increased costs and no benefit to the patient. Education of providers and patients is needed to overcome this psychological stereotype that more is better and that screening will reduce cancer mortality, which is not supported by the data, the authors write. Equally important, education can be effective in avoiding underuse of screening and overcoming disparate care needs. “These issues are complex, but it is also the mission of the ACS to try to explain this complex issue, and simplifying and hiding the truth is not possible,” Dr. Brawley said. Medical Oncology Treatment When certain advances have significant efficacy in the treatment of new cancer systems, for example, complexine kinase inhibitors for chronic granulocytic leukemia, most indicators become smaller, increasing efficacy. But regardless of the amount of benefit they provide to patients, these drugs are expensive, with most costing about$10,000 a month. In the United States, drugs tend to be expensive, compared to the rest of the world. The defense from pharmaceutical companies is that the U.S. cross-subsidizes the global market and maintains incentives for new drug development. Regulatory factors and medical reimbursement also contribute to high drug prices. The Centers for Medicare and Medicaid services are not allowed to interfere with prices, and many laws entrust insurance companies to cover oncology drugs, the authors mention. On top of that, the use of coverage labels for drugs has increased. Data from the mid-2000s show that 60-70 percent of cancer patients’ medications are administered with a covered label. The use of covered-label drugs is not inherently wrong; it is that the decision to regulate lags behind the evidence or the evidence is not found, even when there is evidence of drug efficacy in the treatment of specific diseases. Nonetheless, the use of high-cost cancer drugs with override labels increases the cost of care. The authors focus on the number of completed studies, especially those non-randomized controlled trials that yielded high levels of data. It is thought that these increased numbers of small studies may be the result of companies rolling out data in an attempt to accumulate enough evidence, albeit without high levels of evidence, to obtain reimbursement for covered label drugs. Similarly, payment mechanisms can generate financial incentives for specific treatments in terms of official management of intravenous drug use by oncologists. In this case, new drugs receive adequate reimbursement while older drugs lose out. Because of the current system, standard chemotherapy drugs are not related to efficacy and possible value. This reimbursement system is not consistent with high-value care for internists, and higher patient consumption will drive higher costs. An interesting study found that most patients with lung metastases or colon cancer believe they may be cured by chemotherapy. Therefore, there is a need to communicate the true value of non-curative treatments, the authors note. Radiation therapy and surgery Just as in medical oncology, fee-for-service payment systems can stimulate the adoption of radiation therapy or surgical techniques, the latter of which can often be highly reimbursed. This is despite a lack of comparable evidence to show its benefits, the authors report. For example, studies have shown a rapid, increased use of brachytherapy in breast cancer patients, and the use of modulated intensity radiation therapy in prostate and breast cancer patients, but there is no high level of evidence of its effectiveness. This is an example of how difficult it is to change practice, and a randomized study showed that low-cost single-site radiation therapy was as effective in controlling pain as high-cost multi-site radiation therapy. Nevertheless, a recent analysis of survey, epidemiologic and evidence-based data shows that multi-site radiation therapy remains available, even in the last month of life. Dr. Benjamin Smith, professor of radiation oncology at the University of Texas Medical Cancer Center at Houston, notes that it is often difficult to understand and quantify the value and long-term effects. And while it’s clear that a single site is indicative of palliative care for a patient with end-stage disease, there are other situations that are unclear. “A patient comes in with humeral pain from metastatic prostate cancer,” Dr. Smith said, adding that single-site radiation therapy can provide the same pain control and is inexpensive, so it should be given and the patient can experience significant pain relief. But six months later, the tumor had spread, and an impending fracture required orthopedic surgery to stabilize it. Should the patient get better tumor control with fewer fractures and thus avoid surgery? The answer is not clearly known here. However, it illustrates that value assessment is complex. Robotic surgery is discussed as a technology, but its increased cost may or may not add value to the surgical treatment of cancer. Many of the new radiotherapy, surgical devices licensed through the FDA do not have corresponding comparable clinical trials to prove their effectiveness. However, media attention and patient interest are high, and robotic surgery has pros and cons and can result in a 13% increase in overall surgical costs. Observational studies have shown that robotic total prostatectomy has fewer postoperative complications compared to open surgery and lower mortality during prostatectomy and cyst removal, but is also accompanied by more genitourinary complications (compared to open surgery,. Even though surgical outcomes are clearly inconsistent, robotic surgery allows for more experience and rapid mastery of the technique. Quality and cost considerations for robotic surgery should be a concern, especially in low-volume hospitals, the authors write. Supportive care End-stage care is an area for improvement. Many studies have shown that patients who receive intensive treatment become worse at the end of life. Palliative care early in the disease process has been shown to improve the quality and length of life. A randomized trial of patients with metastatic non-small cell lung cancer showed that instituting palliative care at the time of diagnosis improved life treatment and reduced depression. Because these patients receive less end-stage chemotherapy and therefore save money, there are fewer emergency room visits and hospitalizations. While there are difficulties in doing so, internists need to do a better job of advocating and communicating with patients, providing real information regardless of their prognosis, the authors write. The authors write. The data show that patients and their families prefer accurate prognostic information prior to informed consent. Implementing Change In summary, the authors argue that the cost drivers of cancer care include an aging U.S. population, inappropriate overuse of medical technology, growing research and development costs, unsupported public demand for services, and unrealistic patient expectations. Aging cannot be changed, but other drivers can be controlled. The authors emphasize that cost-friendly factors span all oncology specialties, and the American Board of Internal Medicine has launched a campaign calling for “smart choices” to control overmedication across multiple specialties (JAMA. 2012;307:1801-1802. The American Society of Clinical Oncology is involved and has published 2 of 5 rankings in oncology treatment. 5 rankings in the practice of oncology (J Clin Oncol. 2012;301715-1724). Do not give antiemetics that are not needed before chemotherapy when only mild or moderate vomiting is possible. Do not use cancer pointing therapy in patients with solid tumors, ECOG PS of 3 or 4, without prior evidence of benefit from intervention, without controlled clinical trials, or without strong evidence to support the value of antineoplastic therapy. Do not use multi-subject chemotherapy regimens in place of single-subject chemotherapy regimens in patients with metastatic breast cancer unless a rapid response is required. Do not perform PET, CT, or radiographic bone imaging in patients with early stage prostate cancer at low risk of metastasis. Avoid routine PET scans for monitoring the recurrence of cancer unless there is a high level of evidence that it will alter the outcome. Do not perform PET, CT, or radiographic bone imaging in patients with early stage pre-breast cancer at low risk of metastasis. Do not perform prostate screening in asymptomatic men with a life expectancy of less than 10 years. Do not use routine biomarkers or imaging (CT, PET, or bone scan, in individuals with asymptomatic already treated breast cancer. Do not use targeted therapies that target specific genetic variants unless the patient’s tumor has a biomarker that predicts effectiveness. Do not use leukocyte disrupting factors in patients with febrile neutropenia who are at less than 20% risk of complications. As an economist, I believe it is human nature to respond to economic stimuli, Dr. Shih said. This study will provide many examples of how the current fee-for-service reimbursement system encourages overuse and creates waste. I’m not saying we should do away with the fee-for-service payment system altogether, but I don’t think certain changes are necessary, and changes should correspond better to stimulating the delivery of high-value care, not just new, expensive therapies. The authors argue that patients are unique and individualized care is important, but that adherence to high-quality evidence will improve the quality and value of care and limit under- or overuse. Finally, a multidisciplinary approach is needed: high-level evidence must be available before treatment strategies are adopted; end-stage care must be more rational; and communication must improve through electronic medical records, the latter accessible across institutions. Payment reform and coordination of care in which all providers should share resources, risks, and reimbursement mechanisms help stimulate the emergence of demand; patients need to be educated so that their expectations are more realistic and not influenced by market manipulation, which drives excessive or low output interventions. Ultimately, we want to see the health care system allocate our limited resources efficiently; Dr. Shin added that we are not saying that internists should do less or get paid less to cross boards to reduce costs. What we are saying is that we should allocate resources efficiently to ensure equal access to care, but discourage minimal or no benefit treatment. The entire payment system is not constructed to compensate for value, Dr. Smith added, and more complex treatments come along that you need to pay more for. We need to point out how to stimulate value, not just do more to get paid more.