Journal of Surgical Oncology 2014;110:643–644
EDITORIAL Enlightened Oncologists can Provide Quality Cancer Care at Reduced Costs C. R. BEENA DEVI,
MD, MMed (Pall Care)*
Sarawak General Hospital and Department of Radiotherapy, Oncology & Palliative Care, Jalan Hospital Kuching, Sarawak 92586, Malaysia
Health care costs have risen dramatically over the last few decades. Based on the report by the U.S. Bureau of Census, the population aged 65 years and older is expected to increase from 40 million in 2009 to 70 million in 2030 [1]. As cancer incidence is highest in the elderly, the impact of these population changes on cancer prevalence may exceed the impact of declining cancer incidence rates for some cancers. With new tools for diagnosis and novel targeted therapies developed in oncology, both the number of cancer survivors and cancer treatment expenditures are likely to increase in the future [2]. Cancer costs are greatest during the period of initial treatment immediately following diagnosis and during the last few months before death. Hospitalizations are the single largest component of cost for most tumour sites across phases of care, although the proportion varies by tumour site. Due to the dynamic nature of health‐care delivery systems and innovations in cancer treatments, it is imperative that the cost of cancer care be developed based on category of service, such as surgery, chemotherapy, radiation therapy, inpatient care, supportive care, and hospice care in order to optimise care versus cost. The impact of cancer and cancer treatment costs has grabbed the attention of health care providers as well as patients and their families. Economic studies are most useful when an intervention is associated with a better clinical outcome but at greater cost, or when it is associated with lower cost but the same or even less favourable outcome [3,4]. When clinical effectiveness is the same, a cost‐minimization analysis may be utilized to define the approach with the lowest cost. Where clinical or quality‐adjusted effectiveness differ, economic analyses are generally based on cost‐effectiveness, which estimates the added cost per life year gained [3,4]. Such approaches attempt to compare and identify the least costly approach with the greatest effectiveness. Several approaches have been used to estimate costs of cancer care, including incidence, prevalence, and phase‐of‐care approaches [5]. The phase‐of‐care approach divides care into clinically relevant periods: (i) the initial period after diagnosis; (ii) the last year of life; and (iii) the intervening or continuing period. This has an advantage of allowing estimation of long‐term costs of care when applied to survival life tables. The net costs of cancer care were generally higher for patients diagnosed with distant disease than for patients diagnosed with localized disease. For cancers that are rarely diagnosed at early stages and with relatively short survival duration (ie., esophageal, gastric, lung, and pancreatic cancers), differences in cost by stage at diagnosis were smaller [6]. The use of sophisticated diagnostic tools has added to the cost of cancer treatment. Cancer biomarkers provide information about pathophysiological processes that can be objectively measured and evaluated in order to detect or define disease progression, or to predict treatment response. Such use of cancer biomarkers to guide treatment can confer both clinical and economic benefits. For example, in the study by Lindenmann et al. published in this issue of the Journal, the authors demonstrated that elevated levels of C‐reactive protein and
ß 2014 Wiley Periodicals, Inc.
hypoalbuminemia are correlated with survival in patients who present with advanced, inoperable esophageal cancer [7]. Elevated C‐reactive protein and hypoalbuminemia are significantly associated with reduced survival and are considered to be an appropriate predictor for poor outcome in advanced esophageal cancer. Patients with esophageal carcinoma frequently present in advanced stage with reduced nutritional as well as performance status. Tools to evaluate clinical and tumour progression in patients with esophageal carcinoma are rare. In addition, poor prognosis is often associated with poor quality of life and a high rate of clinical complications for the remaining period of their lifetime. Alternatively, prediction of individual survival is often inaccurate, resulting in “ambitious” cancer therapy [8]. Such therapies have given rise to increase in health‐care costs with little or no added benefit to the patient. In a physician‐patient discussion, cost should never become the sole focus, and neither should that alter recommendations for proven effective treatment in an effort to ration care. Preferably, we must look for strategies that may limit the economic impact of these emerging technologies. Investigators should be encouraged to search for value‐ added prognostic and conventional clinical indicators. Such strategies have the potential of enhancing both the effectiveness and cost effectiveness of valuable treatments by targeting agents toward patients most likely to benefit from specific treatments. However, the greatest challenge that clinicians face is not only in communicating both the complex clinical situations and treatment options but also the ensuing costs of care in a practical and thoughtful manner. The study by Lindenmann et al. has clearly highlighted that the use of simple tests like C‐reactive protein and albumin levels will provide clinicians with valuable information as to the type of treatment that might be offered to the patient; particularly, in elderly patients with esophageal carcinoma where radical treatment may not be a viable solution [7]. Selecting the most appropriate treatment in such cases need not be daunting. Clinical assessment with appropriate investigations will provide sufficient information for a thoughtful discussion with patient and family. From time to time, we clinicians lack the right assessment tools to make the optimal decision. The above study by Lindenmann et al. has elegantly demonstrated that simple blood tests with the Glasgow Prognostic Score will assist in better treatment decision making [7]. Hence, needless surgery or radical radiotherapy can be eschewed. Extended hospitalisation for
*Correspondence to: Beena Devi, Sarawak General Hospital‐Radiotherapy, Oncology & Palliative Care, Jalan Hospital Kuching, Sarawak 93586, Malaysia. E‐mail: [email protected] Received 24 June 2014; Accepted 30 June 2014 DOI 10.1002/jso.23746 Published online 13 August 2014 in Wiley Online Library (wileyonlinelibrary.com).
644
Devi
complications of treatment impairs quality of life. Patients with advanced stage of disease usually prefer to spend more time at home with family and friends. The simple tests with clinical assessment of the patient as described in this article are cost‐effective in making decisions on treatment. These tests can be adopted in routine clinical practice and the usefulness of these tests can be validated. The ensuing suffering of patients who are subjected to treatments with little benefit can hence be avoided. Furthermore, not only the patient’s suffering can be alleviated but that of the family and friends too. When clinicians begin to be cognizant of the outcomes of treatment and embrace the idea that less treatment can indeed have more benefit to the patient, the current escalation of health care costs in some instance may be curtailed. The small steps taken by enlightened clinicians on that long journey may be the beginning of a new future for rational health care at reduced costs.
2. 3. 4. 5. 6. 7.
REFERENCES 1. U.S. Census Bureau. Population division. Interim projections consistent with census 2000 (released March 2004). Washington
Journal of Surgical Oncology
8.
D.C.: U.S. Census Bureau, Population Division 2008;http://www. census.gov/population/www/projections/usinterimproj/.Accessed July 2008. Warren JL, Yabroff KR, Meekins A, et al.: Evaluation of trends in the cost of initial cancer treatment. J Natl Cancer Inst 2008;100:888–897. Lyman GH, Djulbegovic B: Understanding economic analysis. Evidence‐based Oncol 2001;2:2–5. Lyman GH: Economics of cancer care. J Oncol Practices 2007; Fireman BH, Quesenberry CP, Somkin CP, et al.: Cost of care for cancer in a health maintenance organization. Health Care Financ Rev 1997;87:51–76. Yabroff RK, Lamont EB, Mariotto Angela, et al.: Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 2008;100:630–641. Lindenmann J, Koesslbacher M, Neuboeck N, et al.: The influence of elevated levels of C‐reactive protein and hypoalbuminemia on survival in patients with advanced inoperable esophageal cancer undergoing palliative treatment. J Surg Oncol 2014;DOI: 10.1002/ jso.23711 Glare P: Clinical predictors of survival in advanced cancer. J Support Oncol 2005;3:331–339.
EDITORIAL Enlightened Oncologists can Provide Quality Cancer Care at Reduced Costs C. R. BEENA DEVI,
MD, MMed (Pall Care)*
Sarawak General Hospital and Department of Radiotherapy, Oncology & Palliative Care, Jalan Hospital Kuching, Sarawak 92586, Malaysia
Health care costs have risen dramatically over the last few decades. Based on the report by the U.S. Bureau of Census, the population aged 65 years and older is expected to increase from 40 million in 2009 to 70 million in 2030 [1]. As cancer incidence is highest in the elderly, the impact of these population changes on cancer prevalence may exceed the impact of declining cancer incidence rates for some cancers. With new tools for diagnosis and novel targeted therapies developed in oncology, both the number of cancer survivors and cancer treatment expenditures are likely to increase in the future [2]. Cancer costs are greatest during the period of initial treatment immediately following diagnosis and during the last few months before death. Hospitalizations are the single largest component of cost for most tumour sites across phases of care, although the proportion varies by tumour site. Due to the dynamic nature of health‐care delivery systems and innovations in cancer treatments, it is imperative that the cost of cancer care be developed based on category of service, such as surgery, chemotherapy, radiation therapy, inpatient care, supportive care, and hospice care in order to optimise care versus cost. The impact of cancer and cancer treatment costs has grabbed the attention of health care providers as well as patients and their families. Economic studies are most useful when an intervention is associated with a better clinical outcome but at greater cost, or when it is associated with lower cost but the same or even less favourable outcome [3,4]. When clinical effectiveness is the same, a cost‐minimization analysis may be utilized to define the approach with the lowest cost. Where clinical or quality‐adjusted effectiveness differ, economic analyses are generally based on cost‐effectiveness, which estimates the added cost per life year gained [3,4]. Such approaches attempt to compare and identify the least costly approach with the greatest effectiveness. Several approaches have been used to estimate costs of cancer care, including incidence, prevalence, and phase‐of‐care approaches [5]. The phase‐of‐care approach divides care into clinically relevant periods: (i) the initial period after diagnosis; (ii) the last year of life; and (iii) the intervening or continuing period. This has an advantage of allowing estimation of long‐term costs of care when applied to survival life tables. The net costs of cancer care were generally higher for patients diagnosed with distant disease than for patients diagnosed with localized disease. For cancers that are rarely diagnosed at early stages and with relatively short survival duration (ie., esophageal, gastric, lung, and pancreatic cancers), differences in cost by stage at diagnosis were smaller [6]. The use of sophisticated diagnostic tools has added to the cost of cancer treatment. Cancer biomarkers provide information about pathophysiological processes that can be objectively measured and evaluated in order to detect or define disease progression, or to predict treatment response. Such use of cancer biomarkers to guide treatment can confer both clinical and economic benefits. For example, in the study by Lindenmann et al. published in this issue of the Journal, the authors demonstrated that elevated levels of C‐reactive protein and
ß 2014 Wiley Periodicals, Inc.
hypoalbuminemia are correlated with survival in patients who present with advanced, inoperable esophageal cancer [7]. Elevated C‐reactive protein and hypoalbuminemia are significantly associated with reduced survival and are considered to be an appropriate predictor for poor outcome in advanced esophageal cancer. Patients with esophageal carcinoma frequently present in advanced stage with reduced nutritional as well as performance status. Tools to evaluate clinical and tumour progression in patients with esophageal carcinoma are rare. In addition, poor prognosis is often associated with poor quality of life and a high rate of clinical complications for the remaining period of their lifetime. Alternatively, prediction of individual survival is often inaccurate, resulting in “ambitious” cancer therapy [8]. Such therapies have given rise to increase in health‐care costs with little or no added benefit to the patient. In a physician‐patient discussion, cost should never become the sole focus, and neither should that alter recommendations for proven effective treatment in an effort to ration care. Preferably, we must look for strategies that may limit the economic impact of these emerging technologies. Investigators should be encouraged to search for value‐ added prognostic and conventional clinical indicators. Such strategies have the potential of enhancing both the effectiveness and cost effectiveness of valuable treatments by targeting agents toward patients most likely to benefit from specific treatments. However, the greatest challenge that clinicians face is not only in communicating both the complex clinical situations and treatment options but also the ensuing costs of care in a practical and thoughtful manner. The study by Lindenmann et al. has clearly highlighted that the use of simple tests like C‐reactive protein and albumin levels will provide clinicians with valuable information as to the type of treatment that might be offered to the patient; particularly, in elderly patients with esophageal carcinoma where radical treatment may not be a viable solution [7]. Selecting the most appropriate treatment in such cases need not be daunting. Clinical assessment with appropriate investigations will provide sufficient information for a thoughtful discussion with patient and family. From time to time, we clinicians lack the right assessment tools to make the optimal decision. The above study by Lindenmann et al. has elegantly demonstrated that simple blood tests with the Glasgow Prognostic Score will assist in better treatment decision making [7]. Hence, needless surgery or radical radiotherapy can be eschewed. Extended hospitalisation for
*Correspondence to: Beena Devi, Sarawak General Hospital‐Radiotherapy, Oncology & Palliative Care, Jalan Hospital Kuching, Sarawak 93586, Malaysia. E‐mail: [email protected] Received 24 June 2014; Accepted 30 June 2014 DOI 10.1002/jso.23746 Published online 13 August 2014 in Wiley Online Library (wileyonlinelibrary.com).
644
Devi
complications of treatment impairs quality of life. Patients with advanced stage of disease usually prefer to spend more time at home with family and friends. The simple tests with clinical assessment of the patient as described in this article are cost‐effective in making decisions on treatment. These tests can be adopted in routine clinical practice and the usefulness of these tests can be validated. The ensuing suffering of patients who are subjected to treatments with little benefit can hence be avoided. Furthermore, not only the patient’s suffering can be alleviated but that of the family and friends too. When clinicians begin to be cognizant of the outcomes of treatment and embrace the idea that less treatment can indeed have more benefit to the patient, the current escalation of health care costs in some instance may be curtailed. The small steps taken by enlightened clinicians on that long journey may be the beginning of a new future for rational health care at reduced costs.
2. 3. 4. 5. 6. 7.
REFERENCES 1. U.S. Census Bureau. Population division. Interim projections consistent with census 2000 (released March 2004). Washington
Journal of Surgical Oncology
8.
D.C.: U.S. Census Bureau, Population Division 2008;http://www. census.gov/population/www/projections/usinterimproj/.Accessed July 2008. Warren JL, Yabroff KR, Meekins A, et al.: Evaluation of trends in the cost of initial cancer treatment. J Natl Cancer Inst 2008;100:888–897. Lyman GH, Djulbegovic B: Understanding economic analysis. Evidence‐based Oncol 2001;2:2–5. Lyman GH: Economics of cancer care. J Oncol Practices 2007; Fireman BH, Quesenberry CP, Somkin CP, et al.: Cost of care for cancer in a health maintenance organization. Health Care Financ Rev 1997;87:51–76. Yabroff RK, Lamont EB, Mariotto Angela, et al.: Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 2008;100:630–641. Lindenmann J, Koesslbacher M, Neuboeck N, et al.: The influence of elevated levels of C‐reactive protein and hypoalbuminemia on survival in patients with advanced inoperable esophageal cancer undergoing palliative treatment. J Surg Oncol 2014;DOI: 10.1002/ jso.23711 Glare P: Clinical predictors of survival in advanced cancer. J Support Oncol 2005;3:331–339.
