Emerging targeted therapies are extending survival rates for many cancers, but the cost of these new treatments is often prohibitive. Many medications prescribed at the final stage of cancer treatment extend a lifespan by only a few months at most. As a result, as new therapies become available in clinical practice, questions about cost versus benefit are increasingly emerging. Among the often difficult questions being asked: Are survival gains for a patient worth the burden on the healthcare system and the patient? How do we pay for these new drugs, technologies and diagnostic procedures—and who should pay?
To gain perspective on these issues, Targeted Therapy News spoke with Thomas J. Smith, MD, director of Palliative Medicine at The Sidney Kimmel Comprehensive Cancer Center and professor of Oncology at Johns Hopkins Medical School in Baltimore, Maryland. Smith discussed the rising cost of cancer therapies, the burden of cost, and the cost-benefit analysis of end-of-life care, and will also speak about these issues at the 2012 annual meeting of the American Society of Clinical Oncology (ASCO) in a session titled, “Costs of Cancer Care: Affordability, Access, and Policy.”
Following are excerpts from the conversation published on OncLive.com.
The cost of end-of-life care is very high for cancer patients. How do oncologists reconcile these costs with providing the best treatment for their patients, while also recognizing whether the quality of life may be more important for a patient with advanced-stage cancer?
Many of us were trained to treat the disease and as long as there is something that can be done, to keep treating as long as it does not make the patient deathly ill. This has worked for our patients for the most part. Sometimes, I think the deathly ill part gets neglected a little bit because we tend to ask less about our patients’ quality of life than we should.
What role does palliative care play?
Palliative care was always designed to improve patients’ symptoms and coping, to lessen depression, and to lessen caregiver burden. It is only an interesting sidebar that it results in cost savings. The cost savings are substantial. It could be anywhere from 20% to 50% of the cost in the last month or six months of life that can be reduced. This type of care allows patients to get out of the hospital, where most people don’t want to be.
What are some of the ways that oncologists can curb costs while providing good care for patients at the end of life?
There are a couple of strategies for oncologists that make good sense. One is to get people into a care system that keeps them out of the hospital near the end of life. The best way to do this is hospice. ASCO and many of us who are practicing oncologists are now recommending that when patients have about three to six months left to live, they should visit a hospice for information. This does a few things. It makes it real for the patient and the family that this is where things are headed and it is time to plan. It introduces the hospice team as the best way to take care of people at the end of life—which all professional societies agree on, every single one. It introduces the hospice care team as part of the regular oncology care plan. Integrating the hospice early is now part of best practices for most oncologists. It makes the transition easier, so that when a patient has tried a third-line chemotherapy in lung cancer or colorectal cancer without success, the oncologist can say, “Now is the time for you to switch to the hospice care,” with the nurses and social workers that the patient has already met.
ASCO released palliative care guidance in March of this year. How do you see this being implemented?
Palliative care should be a part of the care of anyone with a serious illness. The uptake should not be slow. All of us who are practicing oncologists work with hospice providers. I like to use the analogy of we know the radiation therapist and our surgeons very well. We know their phone numbers and their fax numbers probably by heart. For the hospice providers, it tends to be a love-hate relationship. It shouldn’t be that way. It should be part of the normal process of care. I think oncologists like me should be calling the hospice providers and saying, “We actually work a lot together. Let’s figure out what we can both do to improve the care our patients get.” Hospice providers like to see patients when they have at least a month to live rather than a day left to live. It is a terrible process of care when we simply avoid having this conversation until the patient is bed-bound, in renal failure, and has an infection and two days left to live. In this situation, hospice is just scurrying around and doesn’t even have a chance to speak to the patient, and is left to pick up the pieces for bereavement and grief counseling. Patients in hospice care and with palliative care tend to live longer rather than shorter.
Oncologists should speak to the hospice providers to understand how they can do better. We should ask them how our statistics compare to the national average in terms of referral time. As oncologists, we need to be having realistic conversations about how many treatment types a patient can go through before we run out of options. Saying that there is a limit to treatments and there will be a time when treatment will only do more harm than good is necessary. This conversation needs to happen early and be reinforced throughout treatment.