What Does Value in Cancer Care Mean?

What Does Value in Cancer Care Mean?

Julie Vose, MD, MBA, FASCO

Jan 29, 2016

In the face of limited health care resources and a rising national health budget, it is important to consider value when making treatment decisions for patients with cancer. This is a key question for all of us involved in cancer care and research. The answer may be a bit different coming from the viewpoint of the different stakeholders. One of my favorite quotes is from fellow Omaha native Warren Buffett “Price is what you pay. Value is what you get.” Let’s evaluate the different viewpoints on value in cancer care:

1. Patients: As health care providers, we think that value of cancer care for a patient is the same as what we consider, such as increased time without evidence of the cancer associated with the lowest cost of care. However, patient interviews demonstrate an alternative viewpoint. A survey of 769 patients with metastatic breast cancer were asked to define value in cancer care. Many of the responses defined this as “information and appropriate communication of information in the right time and place,” or “the amount of time spent with the physician or medical team.” On the other hand, only 7.4% of the patients defined value in an economic context. An example of these comments would be “value in cancer treatment is getting the best options at the lowest cost, presented to you in a manner that is easily comprehended”. Many more of the responses related to value centered around quality of life and feeling well enough to engage in meaningful functions.1 This is a view of value that is much broader than most of the health care system might think of when we use the term “value in cancer care.”

2. Physicians: Cancer care providers want to administer the treatments that give the best clinical outcome with the most manageable toxicities at the lowest cost. However, critical information is needed to gather the specifics to analyze the data to provide the evaluation. There is always a concern about oncology therapies to be sure that the balance between the additional cost and possible toxicities are balanced with the clinical improvements. What constitutes a meaningful improvement in the clinical outcome to warrant what additional cost? As physicians we often lean on the side of improvement in outcomes without specifically thinking about the additional costs to the patient or the health care system and society. We may need to consider a more balanced approach.

3. Health Insurers/Society: Companies or the government who have the perspective of a larger population are often caught between the patient and physician who want access to every treatment and the newest technology and employers or funders of the insurance who demand that the health care funds are spent with the highest value care in mind. Insurers have developed guidelines, pathways, and tools to use evidence-based medicine for cancer care. We need to balance the options for therapy with the potential for improvement in the patient’s disease control and quality of life. The involvement of cancer specialists and patient advocates in the development of treatment strategies and pathways are key to successful programs that are a coordinated effort.

A combined statement of value in cancer care might be defined as patients, families, physicians, health care institutions and health insurers all agreeing that the benefits afforded by the interventions are sufficient to support the total sum of resources expended for its use. If all parties can agree on what constitutes value in cancer care, the pathway forward would be much clearer for all stakeholders.


  1. Survey results presented at the 5th Annual Conference of the Association for Value-Based Cancer Care.


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L. Michael Glode, MD, FACP, FASCO

Jan, 16 2016 11:10 AM

Dr. Vose has made some excellent points and ones that the oncology community must continue to struggle with. I would add a 4th stakeholder whose voice is often one of the most influential in health care discussions, namely the pharmaceutical industry. Operating through capitalism (with all that is good and bad about it), the "invisible hand of the market" has enormous influence in the value discussion. With the introduction of an avalanche of targeted therapies that produce some dramatic responses, a new era of oncology is upon us. However, despite individual miraculous tumor regressions, some hopefully permanent, "cure" remains elusive much of the time and in the larger context we observe survival curves that reflect incremental improvements such as 5 month overall benefit in survival with significant P values due to the size of the studies. "Personalized [genomic] medicine" provides hope that the right drug can be matched to the right patient, improving this scenario, however the mutational forces of genomic instability so nicely explained in "The Emporer of All Maladies", that result in vast heterogeneity remain daunting. Equally challenging (both economically and functionally from a molecular standpoint) would be finding a personalized cocktail to attack all of the driver mutations followed by immunologic manipulation to handle the residual tumor cells.

In my own clinical experience, when discussing an exceptional drug (both in terms of effects, at least short term, and cost, which I choose not to ignore because of both co-pay issues and the larger societal issues), patients will often conclude their thinking with a statement something like, "Well, I might as well try it. What choice do I have?" In certain contexts the choice might be hospice or no further treatment at all, and I am careful to describe those to the patient in a holistic and hopefully supportive/sensitive manner. But what if there really was a choice? What if I could say that the patient could choose between an expensive drug with limited effectiveness and supportive care with some portion of the "savings to society" going to a charity or to the patient's grandchild's education fund? I fully recognize this is an anathema to many, especially ethicists, but in the real world of my clinic, I have the impression that many patients might choose to value an alternative to marginally effective, high cost treatments. After all, presumably they have been making such choices throughout their lives when it came to face lifts, tooth whitening, or other cosmetic procedures. Empowering individual patients will ultimately be necessary if we believe that controlling health care costs is an essential aspect of preserving our larger societal values.

Julie Vose, MD, MBA, FASCO

Jan, 16 2016 3:03 PM

Thanks Dr. Glode for your very thoughtful comments on the value of cancer care at the patient level.  Many times oncologists, patients, and families are optomistic about therapies that have marginal benefits as you described.  When we see patients to discuss options we need to be optomistic, but realistic about the data and the cost for the patient  - in terms of personal toxicities and financial toxicities.  It is often difficult during a busy clinic to have adequate time for these discussions, but that is our duty to the patients with a cancer diagnosis who are looking for options and information.  Hopefully we can find a way in the US healthcare system to offer the best oncologic care with a high value for the patients and families.

Julie M. Vose, M.D., M.B.A.


Helmy M. Guirgis, MD

Jan, 18 2016 1:55 PM

Thank you Dr. Vose for stressing the value of value-based care. My remarks are focussed on costs of anti-cancer drugs and the value we get in return. There has been an emerging view that costs matters more than costs. There were wide varaiations in cost assessment between survival and HR- linked values of drugs in metastatic castrate-resistant cancer. There were drugs approved at  hazatd ratios (HR) of 0.8 or more with survival of 120-140 days. If you calculate values based on one and not the other, the results would be misleading. Not to mention, i do not like the term HR since it is frightining to some patients. It is better to use "Probabilty of survival" (PoS) calculated as (1.0 - HR). The PoS is gentler and less threatening. Thank you again for well thought point of view.

Value of Anticancer Drugs in Castrate-Resistant Metastatic Prostate Cancer; Economic Tools for the Community Oncologist, JCSO 2015;13:362-366.

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