Should We Teach Cost-Effectiveness of Cancer-Related Therapies in Oncology Training?

Should We Teach Cost-Effectiveness of Cancer-Related Therapies in Oncology Training?

Guest Commentary

Apr 27, 2021

By Samer Al Hadidi, MD, MS, FACPDr. Samer Al Hadidi

The list of options of cancer therapeutics continue to grow. While adding more effective choices to treat patients with cancer is exciting, the cost of cancer care is becoming more problematic.1 The Accreditation Council for Graduate Medical Education (ACGME) requires faculty members involved in graduate medical training in hematology, as well as medical oncology, to be able to demonstrate commitment to the delivery of safe, high-quality, cost-effective, patient-centered care as one of the training core measures.2 However, formal training in cost-effectiveness is not usually required for either faculty members or trainees. Implementation of a well-structured, oncology-based cost-effectiveness training for both faculty members and trainees will be of paramount importance and should be prioritized as a significant urgent change in training curriculum. 

Economic efficiency is important when evaluating medical treatments. Cost is not only about the price of a drug or intervention. It includes many other aspects that are either related to patients or healthcare systems. Economic efficiency simply asks the question: Are we getting the best outcome for the expenditure? Or are we minimizing cost for the outcome achieved? While the vast majority will agree that human life is priceless, most of the approved cancer drugs in the recent years are based on cancer control rather than overall survival.3 Better cancer control may lead to improved survival or quality of life; however, this is not necessarily true and is extremely variable between different cancers, patients and treatment options. 

The aims of economic evaluation of cancer treatments are to allocate resources within the healthcare system and to determine whether resources would be better used for a given healthcare intervention, or for some other purpose. There is a lack of teaching of the tools that are used to assess economic evaluation which include: cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis. Those specific measures are rarely taught in oncology training. 
 
Cost-effectiveness analysis is usually measured by incremental cost-effectiveness ratio (ICER) and it establishes how much extra has to be paid for extra benefit. The ideal new treatment is the one that is more effective and lower-priced. This is rarely the case because effective newer therapies are usually associated with higher prices; thus, determining that the maximum acceptable ICER will serve as a guide that may help in determining a price limit to a given intervention according to the effectiveness of treatment.
 
Cost-utility analysis, a subset of cost-effectiveness analysis, measures quality-adjusted life years (QALY’s) which is considered the standard measure in the U.S. For example, one year of life is valued less if a patient is severely disabled than if a patient is not disabled. Cost-benefit analysis goes one step beyond cost-effectiveness analysis by placing a dollar value on medical outcomes. It is controversial to place a dollar value on human life or health, thus the use of cost-benefit analysis may not be encouraged.  
 
While cost-effectiveness may sound difficult to understand and/or implement, a specific curriculum to teach the most important aspects related to cost-effectiveness and cancer therapeutics can be feasible.  Efforts from organizations such as the American Society of Clinical Oncology (ASCO) and others are important. The ASCO Value Framework assesses the value of new cancer therapies based on clinical benefit, adverse events, and improvements in patient symptoms or quality of life in the context of cost.4,5 Workshops that target trainees or early-career faculty are potential solutions and can be planned as part of annual meetings. It is important to note that not all fellowship programs will be able to provide specific teaching on cost-effectiveness, therefore a common curriculum that is created and distributed among all fellowship programs can be helpful. A suggested 3-hour curriculum to cover specific topics in economic efficiency is summarized below:
Economic Efficiency Curriculum
There is an increased number of publications that look into cost-effectiveness of various medical therapies.6 While such increment is helpful, trainees and early-career faculty members will need to better understand the process of cost-effectiveness analysis to identify strengths/weaknesses of the models used to create the analysis and to better understand their conclusions. 
 
Training in cost-effectiveness of cancer therapies can be short, concise and re-useable by different fellowship programs at different stages of training. With the current pace of progress in cancer care, urgent implementation of cost-effectiveness training curriculum in fellowship training programs will be indispensable.
 
Dr. Al Hadidi is a third-year fellow in the Section of Hematology and Oncology at Baylor College of Medicine, and is a member of the ASCO Trainee Council. His research interests include areas related to hematologic oncology, with a focus on drug development, health equity and medical education. Follow Dr. Al Hadidi on Twitter @HadidiSamerDisclosure.

 

References

  1. Kantarjian H, Rajkumar SV. Why are cancer drugs so expensive in the United States, and what are the solutions? Mayo Clin Proc. 2015 Apr;90(4):500-4. DOI: https://doi.org/10.1016/j.mayocp.2015.01.014 
  2. ACGME Program Requirements for Graduate Medical Education in Hematology and Medical Oncology. Available at: www.acgme.org/Portals/0/PFAssets/ProgramRequirements/155_HematologyAndMedicalOncology_2020.pdf?ver=2020-06-29-162353-163. Accessed 27 April 2021.
  3. Kim C, Prasad V. Cancer Drugs Approved on the Basis of a Surrogate End Point and Subsequent Overall Survival: An Analysis of 5 Years of US Food and Drug Administration Approvals. JAMA Intern Med. 2015 Dec;175(12):1992-4. DOI: https://doi.org/10.1001/jamainternmed.2015.5868
  4. Schnipper LE, Davidson NE, Wollins DS, et al. American Society of Clinical Oncology. American Society of Clinical Oncology Statement: A Conceptual Framework to Assess the Value of Cancer Treatment Options. J Clin Oncol. 2015 Aug 10;33(23):2563-77. DOI: https://doi.org/10.1200/jco.2015.61.6706
  5. Schnipper LE, Davidson NE, Wollins DS, et al. Updating the American Society of Clinical Oncology Value Framework: Revisions and Reflections in Response to Comments Received. J Clin Oncol. 2016 Aug 20;34(24):2925-34. DOI: https://doi.org/10.1200/jco.2016.68.2518
  6. What is the CEAR Registry. Available at https://research.tufts-nemc.org/cear4/AboutUs/WhatistheCEARegistry.aspx. Accessed 27 April 2021. 

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Comments

Peter Paul Yu, MD, FASCO, FACP

May, 08 2021 11:10 AM

Thank you Samer for articulating the need to raise awareness among oncology fellows on science based methods to assses "value".  ICERs have been mostly used in countries where the national healthcare budget is fixed.  In the U.S. where healthcare is a considered an entitlement without a fixed national Medicare budget, we have largely avoided discussions about comparative effectieness and impact on the national budget.  However, ICERs have limitations,  In particular, the calcuation of  "disutilities", which are how the negative impact on QOL is measured, are not onoclogy derived and need to be better defined for the cancer population https://jitc.bmj.com/content/jitc/7/1/235.full.pdf

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