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Oncologists React to Cost-Cutting Editorial

By Kristina Fiore, Staff Writer, MedPage Today
Published: May 28, 2011

One way to curb rising cancer costs may be to cut back on chemotherapy regimens -- specifically if they're producing no effects after three consecutive rounds.

That's one of 10 recommendations put forth in a New England Journal of Medicine commentary by Thomas Smith, MD, and Bruce Hillner, MD, of Virginia Commonwealth University -- who may be trying to spark debate just ahead of this year's annual meeting of the American Society of Clinical Oncology.

Smith and Hillner argue that spending on cancer treatment must be curbed because it is spiraling out of control, predicted to rise from $104 billion in 2006 to $173 billion in 2020 -- largely driven by rises in the cost of therapy and the extent of care.

"We must find ways to reduce the costs of everyday care to allow more people and advances to be covered without bankrupting the healthcare system," they wrote.

To achieve that, the researchers outlined 10 recommendations for oncologists: five regarding behavior and five focusing on attitudes and practice.

Perhaps their most contentious point was limiting chemotherapy regimens to only three if the patient does not respond well -- restricted, of course, to those with incurable solid tumors.
The idea evoked a strong response from several clinicians contacted by MedPage Today and ABC News.

While some said this recommendation largely reflects the way they've already been practicing, others argued that cancer treatment cannot be so generalized, since there are multiple variables including the type of disease, the available treatments, and the patient's response.

"Reasonable people could accept an approach that allocated resources where they were likely to be effective and withheld resources when they were not likely to be effective," Rosamond Rhodes, PhD, of Mount Sinai School of Medicine in New York City, said in an email.

"In the circumstance in which a person has shown no benefit from three consecutive regimens of chemotherapy, and offering another regimen is not likely to be effective, withholding further ineffective interventions could be acceptable," she added. "A rationing scheme based on a low efficacy standard and applied to all patients with all diseases, could be just, fair, and reasonable."

On the other hand, Bayard L. Powell, MD, of Wake Forest University in Winston-Salem, N.C., warned that treatment decisions are complex, and physicians should make decisions on an individual basis.

"Chemotherapy can be expensive and can be toxic, but it can improve both the quality and duration of life for many patients," Powell said in an email. "It would be very difficult, and inappropriate, to make broad generalizations about how to best use these therapies in a diverse group of patients with cancer."

And being denied treatment -- even if it may not be effective -- is not something patients want to hear, experts said. Herbert Kressel, MD, of Beth Israel Deaconess Medical Center in Boston, relayed the experience of his mother-in-law, who had failed three regimens.

"Her oncologist recommended no further treatments," Kressel said in an email. "Her son, a physician, argued vehemently against this and persuaded the oncologist to go one more round. Needless to say, she was totally cured and lived over 10 additional disease-free years."
Among the other recommendations regarding oncologists' behaviors were getting with the guidelines to cut out surveillance testing with serum tumor markers, and using sequential monotherapy instead of combination regimens for recurrent disease.

They also called for limiting chemotherapies on the basis of patient performance (they should be able to walk themselves into the clinic, Smith and Hillner wrote) and for reducing chemotherapeutic dose as an alternative to giving expensive hematopoietic colony-stimulating factors afterwards, which have shown little benefit.

In terms of physician attitudes and practice, the editorialists called for more talks with patients about end-of-life care, offering better informed consent regarding their expectations, and improved integration of palliative care.

As well, governments and payers should have more discussions about cost-effectiveness and comparative effectiveness, and there should be a change reimbursement so that payments aren't so tied to chemotherapy, they said.