July 2015, Special ASCO Edition

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ASCO’s Value Initiative: A Case-Based Approach

Value-Based Cancer Care

Recent advances in medical technology have led to remarkable breakthroughs in cancer treatments. Unfortunately, new cancer drugs come with enormous price tags, and patients are forced to make difficult decisions about very high out-of-pocket costs for expensive treatments with measurable but sometimes modest health benefits.

The chair of the ASCO Task Force on Value in Cancer Care spoke with the audience about ASCO’s vision of providing all patients with lifelong access to affordable, compassionate, and high-quality care. He also addressed the need to rethink how oncologists value treatment options so that they can help patients make informed decisions.

“Ultimately,” said Lowell E. Schnipper, MD, Chief of Hematology/Oncology and Clinical Director of Beth Israel Deaconess Medical Center, Boston, MA, “we are optimizing a tool that a physician would have at his or her disposal in the office that would help patients understand, for a given clinical indication, what are the possible regimens, what are the ups and downs, and [how to] integrate those with the patient’s personal preferences.”

These preferences often involve finances. Among Medicare expenditures, cancer treatment involves the most expensive drugs and is associated with bankruptcy rates that are nearly double those of the general population.

“What you see along the spectrum of care are individuals making decisions that are probably in part, if not in toto, predicated on financial issues,” he said. “It’s no surprise that the healthcare system has run amok from a financial perspective.”

In response to this pandemic, the task force, a group that represents academia, community practice, the payer community, and the manufacturers, has attempted “to devise a more uniform way of thinking about how best to treat patients for given indications.”

Overall Survival Is the Most Important Variable

Although the group quickly prioritized “clinical benefit” as the key concept driving value in healthcare, translating this concept into a practical, everyday value assessment proved to be a challenge.

The task force ultimately determined that overall survival was the best end point to be presented, and that a clinically meaningful outcome would be a 40% to 50% change in magnitude. Although considered an inferior metric, Schnipper indicated that progression-free survival should be factored into the value equation because it is often all physicians have to work with.

Palliation of symptoms in the context of advanced disease and treatment-free interval—“because that has to be a surrogate for quality-of-life consideration”—are also important variables in the opinion of the task force, along with toxicity.

“In comparing 2 regimens, we felt it fair to begin to think about toxicities,” said Schnipper. “Is one regimen more or less toxic than the other? The clinical value to a patient of having a less toxic regimen cannot be overstated in this setting.”

Considerations of Cost

Last but not least, there’s the issue of cost in assessing value.

Although econometricians often use quality-adjusted life-years saved to make policy decisions related to healthcare expenditure, Schnipper underscored the difficulty in generating “quality” for an individual patient, especially in the setting of advanced disease.

“Patients have very, very particular needs and wishes,” he said. “Some want to avoid toxicity or neuropathy because they’re violinists; some don’t care about length of life but prefer to live a high-quality, comfortable life.”

Context thus becomes a critical focal point of discussion.

“As the cost of care increases—and I’m not talking about the US economy; I’m talking about the patient sitting across from you—people exhaust their savings so their kids may have to delay going to college. Second mortgages on the house are taken, and adherence to the medication is shown to be reduced,” he said.

Schnipper concluded his talk with a dose of humility, acknowledging that physicians and patients may have different understandings of the value in care.

“Patients express a great deal of value for bonding and positive relationships with their healthcare provider team…and perhaps are less preoccupied by some of the things that I just discussed as parameters,” he said. “On the other hand, how do you derive value framework without some concrete scientifically ordained variables that are reproducible from one study to another?”

Ultimately, the task force hopes to provide a user-friendly device that will be available at the physician-patient interface and perhaps, one day, as a tool for public policy.

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