Now that the 2015 ASCO Annual Meeting has drawn to a close, it is with restrained optimism that I have returned home. While we have just spent the last few days learning about exciting innovations in cancer care, it is difficult to think of these advances without considering their cost, and one must attempt to understand how these advances will fold into a values framework.
Over the past few days, multiple perspectives have been presented on what constitutes value in cancer care. It is interesting to hear the evolution of this discussion over the past year. Are we getting closer to arriving at a common ground for all the stakeholders in this discussion? I believe the perspectives of many stakeholders are converging yet I question if the most important of the stakeholders, our patients, are arriving at the same definition of what constitutes value.
We as clinicians understand value in cancer care to be more than clinical benefit alone; adverse effects and cost are part of the value equation.
But our patients may define value differently. For example, Ms. Beverly Canin discussed the results of a research study done by the Cancer Support Community in her presentation Patient Priorities on Value in Treatment Choices, part of the education session The Value Proposition in Oncology: Different Approaches to Understanding Value in Cancer Care. In this study, 769 patients with metastatic breast cancer were asked, “When considering your cancer experience, how do you define value?” Of the sizable number of patients surveyed, very few reported value in terms of clinical benefit relative to cost. The majority of patients who responded defined value in emotional or personal terms, not outcomes relative to cost and toxicity or as “…patient health outcomes achieved per dollar spent,” the definition of value offered by Dr. Michael Porter.
The ability to have fruitful discussions with patients about value requires a mutual understanding of what the concept of value means to each participant in the conversation. A patient may define value in cancer care relative to personal goals, such as that treatment which enables him or her to attend the wedding of a friend or to be present for the birth of a grandchild. The treatment, regardless of cost, may be a dangling carrot that offers the patient hope of meeting personal goals. Many of us have likely cared for patients who wished to try every possible treatment option, regardless of clinical benefit potential. How many patients, when struggling with an uncertain future, have opted for the dangling carrot—that treatment in which, say, only one in 10 people have seen a clinical benefit—albeit a small one—and are willing to take the chance of being in that 10%?
Without a clear understanding of the patient’s perspective on value, a meaningful discussion about clinical benefit versus cost and toxicity of a particular treatment will be rendered even more difficult.
Dr. Saltz, during his compelling talk, Perspectives on Value, at the 2015 ASCO Annual Meeting Plenary Session, described the unsustainable cost trajectory of individual cancer drugs, which have soared from approximately $130/month in the 1970s to about $10,000/month in 2014. Peeling back the layers of how drugs are currently priced is a complex task; however, it is clear that the rising price of cancer drugs will likely erode their “value”, given how we currently understand the concept of value. In the Institute of Medicine’s report Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, one of the recommendations put forth is to “Improve the affordability of cancer care by leveraging existing efforts to reform payment and eliminate waste.” Reforming our payment system without addressing the high cost of drugs, including those for cancer care, would certainly be a disservice to our patients. Drugs that offer a modest clinical benefit and which have minimal toxicity profiles should be accessible to patients; the cost of such drugs should not be prohibitive.
The movement of the U.S. healthcare system toward a value-based system is in progress but will require a culture change from both the provider and patient standpoints. Currently, we may offer treatment options to patients that have minimal clinical benefit with respect to side effects and/or cost, and we must recognize what drives us to do so and change this pattern. Likewise, many patients may be willing to try such treatments—the dangling carrot—which may ultimately lead to diminished quality of life and which are not consistent with an acceptable level of value.
So what is the way forward?
We need to understand our patients’ perspective on value and their goals for treatment of their disease and integrate this information into our discussions with them about treatment options. There are some tools becoming available to aid in communicating value of treatment options to patients:
- The European Society for Medical Oncology’s Magnitude of Clinical Benefit Scale
- The addition of “evidence blocks” to National Comprehensive Cancer Network Guidelines
- ASCO’s Value Framework, to be published later this month
It is also important ro recognize that how a patient defines value may shift over time, and maintaining a dialogue about this and the patient's goals of care is paramount.
It is exciting to see the continued progress in cancer care but the meaning of this progress is diminished when treatments cost too much for patients to benefit from them. We are all stakeholders in ensuring that high quality, cost-effective care is accessible to our patients today and in the future.
I look forward to the continued discussion on value in cancer care and welcome your comments.