On a recent day in hematology clinic, I stood dutifully by my attending as he sorted through bone marrow slides. Upon opening the slide carrier he sighed and asked, “Why did they do all these unnecessary stains? It just drives up the cost, and that affects the patient.”

Although this comment may have seemed offhand, it was just as instructive to me as learning to read an aspirate. Everywhere around us, people are talking about costs in healthcare. The growing concern about soaring expenditures in oncology is hardly news: Google “rising cost of cancer care,” and you’ll find nearly 23 million search results. The hottest topics in medicine today are “cost-conscious” and “high-value” care.

Costs in oncology are rising faster than costs in many other sectors of medicine: cancer care costs increased from $72 billion in 2004 to $125 billion in 2010, and are projected to reach $173 billion by 2020.

 The increasing number of new cancer cases, the costs of emerging therapies, survivorship care, and unnecessary or ineffective testing are all important factors.

Despite advances in cancer prevention, by 2030 the number of new US cancer cases is expected to increase by 45%—from 1.6 million to 2.

 million cases annually—driven largely by our nation’s rapidly aging population.

 Although targeted drugs and immunotherapies show great promise, they are extremely expensive. Eleven of the 12 cancer drugs approved by the FDA in 2012 cost more than $100,000 per year.

 The use of novel cancer therapies in combination with other drugs is costly, even for those who are insured, and high costsharing has already demonstrated negative impacts on medication adherence and health outcomes.

The costs of cancer survivorship also play an emerging role. As care improves, so does survivorship, and currently there are 14.5 million survivors in the United States

 However, it is important to recognize that in addition to the possibility that cancer may recur, survivors are at risk for treatmentrelated comorbidities such as diabetes and cardiovascular disease.

For this reason, multiple healthcare professionals may play a role in a patient’s care, which can affect overall costs of care. One study estimated the economic burden of survivorship to be more than $16,000 annually per patient.

	Discussing “Financial Toxicity”: Is It Equivalent to “Do No Harm?”

Unnecessary testing contributes to excessive costs as well, and may be harmful to a patient. A recent study analyzing outcomes in lung cancer patients demonstrated that physicians who failed to follow established clinical guidelines when providing care to their patients used more invasive testing and had higher rates of complications.

A 2009 guidance statement by the American Society of Clinical Oncology (ASCO) about the overall cost of cancer care advised that physicians “must understand the unique needs of each patient when making treatment decisions, including consideration of out-of-pocket costs.”

 This sentiment was echoed in a 2013 Institute of Medicine report which recommended that oncologists “provide patients and their families with understandable information about cancer prognosis, treatment benefits and harms, palliative care, psychosocial support, and costs.”

Providing patients and their family members with information about costs, perhaps not coincidentally, falls at the end of this long list. Yet, medical debt remains a critical issue for cancer patients and their families.

A recent Kaiser Family Foundation study noted that 1 in 3 Americans reported difficulty in paying medical bills. Although the risk of medical debt is greater for the uninsured, many insured patients also experience difficulty paying their bills.

 Another study demonstrated that cancer patients were 2.65 times more likely to file for bankruptcy than those without cancer.

Medical debt can lead to credit card debt, bankruptcy, barriers to receiving necessary healthcare, and difficulties in paying for basic necessities such as meals and housing. Additionally, cancer can affect a patient’s ability to work, or can prompt a working family member to quit or reduce their hours worked in order to become a caregiver.

Many patients and family members, already struggling with the emotional burden of cancer, don’t know where to seek financial help. Although 75% of pre-retirees believe that their top fear in retirement is uncontrollable healthcare costs,

 only 21% of patients surveyed in a recent analysis actually chose to discuss their fears with a professional.

So why aren’t we talking about it? Both patients and physicians may feel uncomfortable discussing the cost of a potentially lifesaving or life-prolonging treatment option. This in turn presents an ethical challenge: as physicians, shouldn’t we worry about the patient in front of us, and not society as a whole? Taking into account the looming financial burden our patients may face, however, financial toxicity is becoming an important “side effect” to discuss.

Cost concerns are driving the demand for clear evidence of value. However, the difficulty lies in aligning these factors with the best possible patient outcomes. ASCO recently formed a task force to develop a scoring system for evaluating drugs based on their cost, value, efficacy, and side effects. The scoring system is expected to be presented for public comment later this year.

Additional cost-saving measures, such as the use of evidence- based clinical pathways, can minimize variations in cancer care and generate savings by decreasing or eliminating the use of low-value services. The results of an analysis by Neubauer et al demonstrated that outpatient costs in non-small cell lung cancer were nearly 35% lower for patients treated according to an established pathway, with no differences in 12-month overall survival.

Appropriate drug pricing represents a much greater struggle, but physicians are taking a stand. Currently, traditional market forces are largely absent from pricing decisions for new cancer drugs, so there are few competitive pressures to control their costs. One option would be to simply refuse to prescribe drugs based on pricing. Last fall, Memorial Sloan Kettering Cancer Center in New York rejected a new drug for advanced colon cancer because it was twice as expensive as another equally effective drug.

 While this move is admirable, it is not easily (or ethically) reproducible. Attention has turned to debates about funding for comparative effectiveness trials.

	Championing Fellows as the Future Oncology Workforce As fellows in training, what can we do to bend the cost-care curve?

A recent editorial in the New England Journal of Medicine compared ketoconazole with abiraterone in patients with metastatic prostate cancer. The editorial highlighted the cost differences of each drug (costs of ketoconazole were $500-$700 per month, while costs of abiraterone were more than $70,000 per month) and suggested the need for a comparative effectiveness trial. However, the editorial explained that although treating patients with the less expensive drug could generate $1 billion in annual savings, the purchase price of abiraterone (nearly $70 million) would make funding this type of study difficult.

 Another potential solution that has recently become popular in cancer care is to rate the value of treatments based on their cost per quality-adjusted life-year, a method now used by many health economists.

There are a number of ways to become a “Champion of Change.” First, we have to be sensitive to the concerns of our patients and create an open environment where all “toxicities” can be addressed.

To address financial barriers, we must educate ourselves about patient resources such as pharmaceutical programs and nonprofit foundation support that can help enable informed discussions. ASCO provides information to help advise patients on managing the costs associated with cancer care at Cancer.net, and websites such as GoodRx.com can help physicians price drugs available at multiple pharmacies.

We must also think critically about unnecessary testing and therapies. The Choosing Wisely campaign, launched by the American Board of Internal Medicine (ABIM) Foundation, provides resources to help clinicians make informed practice decisions.

In partnership with ABIM’s campaign, ASCO has issued 2 “Top Five” lists designed to raise awareness about costly procedures in oncology practice that should be reconsidered or questioned.

 Additionally, the American Society of Hematology released a similar list in December of 2013, and is currently producing its second list.

 Both societies acknowledge that current challenges include effective implementation and outcomes measurement,

 which represent opportunities for fellows to engage in novel educational programming, use case-based teaching examples where cost and overuse can be readily demonstrated, and design quality-improvement projects within their home institutions.

Most importantly, fellows must familiarize themselves with this important issue and engage patients (and colleagues) in these critical discussions. Becoming a “Champion of Change” will ensure less financial toxicity, more meaningful cancer care, and stewardship of the profession to which we are all committed.

			Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press; 2013.

			American Society of Clinical Oncology. The state of cancer care in America, 2014: a report by the American Society of Clinical Oncology. 

			Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. 

			Oncologists: cancer drugs have become too expensive. The Advisory Board Company website. http://www.advisory.com/daily-briefing/ 2013/04/30/oncologists-cancer-drugs-have-become-too-expensive. Published April 30, 2013. Accessed July 7, 2014.

			Eaddy MT, Cook CL, O’Day K, Burch SP, Cantrell CR. How patient cost-sharing trends affect adherence and outcomes: a literature review. 

			American Cancer Society. Cancer Treatment and Survivorship Facts & Figures 2014-2015. Atlanta, GA: American Cancer Society; 2014.

			Guy GP Jr, Ekwueme DU, Yabroff KR, et al. Economic burden of cancer survivorship among adults in the United States. 

			Almeida FA, Casal RF, Jimenez CA, et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. 

			Meropol NJ, Schrag D, Smith TJ, et al. American Society of Clinical Oncology guidance statement: the cost of cancer care. 

			Pollitz K, Cox C, Lucia K, Keith K. Medical debt among people with health insurance. The Henry J. Kaiser Family Foundation website. http://kff.org/private-insurance/report/medical-debt-among-people- with-health-insurance. Published January 7, 2014. Accessed July 7, 2014.

			Ramsey S, Blough D, Kirchhoff A, et al. Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. 

			More boomers “terrified” of future health care costs. Nationwide Insurance website. http://www.nationwide.com/about-us/120913- nf-healthcare-survey.jsp. Published December 9, 2013. Accessed July 7, 2014.

			Zafar Y, Abernethy AP, Tulsky JA, et al. Financial distress, communication, and cancer treatment decision making: does cost matter? 

			ASCO at work on a scoring system to weigh cost vs. potential benefits of pricey cancer treatments. MedCity News website. http://medcitynews. com/2014/04/asco-scoring-system-cost-effectivenesscancer- treatments. Published April 17, 2014. Accessed July 7, 2014.

			Neubauer MA, Hoverman JR, Kolodziej M, et al. Cost effectiveness of evidence-based treatment guidelines for the treatment of nonsmall- cell lung cancer in the community setting. 

			Bach PB, Saltz LB, Wittes RE. In cancer care, cost matters. The New York Times website. http://www.nytimes.com/2012/10/15/ opinion/a-hospital-says-no-to-an-11000-a-month-cancer-drug.html. Published October 14, 2012. Accessed July 7, 2014.

			Mailankody S, Prasad V. Comparative effectiveness questions in oncology. 

			Woodward RM, Menzin J, Neumann PJ. Quality-adjusted life years in cancer: pros, cons, and alternatives. 

			2012 top five list. Choosing Wisely: ASCO identifies five key opportunities in oncology to improve value of patient care. American Society of Clinical Oncology website. http://www.asco.org/practiceresearch/ 2012-top-five-list. Accessed July 7, 2014.

			ASCO’s 2013 top five list in oncology. American Society of Clinical Oncology website. http://www.asco.org/practice-research/ascos- 2013-top-five-list-oncology. Accessed July 7, 2014.

			Hicks LK. Update on the 2013 ASH Choosing Wisely initiative. American Society of Hematology website. http://www.hematology.org/ Thehematologist/Features/2688.aspx. Published April 10, 2014. Accessed July 7, 2014.

Articles

On a recent day in hematology clinic, I stood dutifully by my attending as he sorted through bone marrow slides

Morganna Freeman- Keller, DO, PGY5

Articles

Becoming a Champion of Change: Educating Fellows on the Costs of Cancer Care