Category Archives: General Treatment Issues

Lowering the Cost of Cancer Treatment

Krista Brooks, Cancer Prevention and Treatment Fund

The number of new cases of the four most common types of cancers (prostate, breast, lung, and colorectal) have been declining since 1998, but Americans are still spending billions in cancer care costs.[1] In 2006, cancer care accounted for an estimated $104.1 billion in medical care spending in the United States and that number will continue to increase in the upcoming years.[1] The National Cancer Institute found that if incidence (which means the number of new cases), survival, and treatment costs stay the same, cancer costs in 2020 will show a 27% increase from 2010 solely based on the growing and aging population in the U.S.[2] As cancer treatment becomes more effective, the increasing number of cancer survivors will require additional care, which will also contribute to overall cost increases.[2] While these trends reflect a changing U.S. population and the increase in cancer survivors, they do not explain why each individual must pay so much for cancer care and treatment.

A survey conducted by the Kaiser Family Foundation found that one in four families affected by cancer say the experience used up all or most of the patient’s  savings, and one in eight say they borrowed money from relatives.[3] For the uninsured, the burden was even higher: “one in four delayed or decided not to get treatment because of its cost.”[3] These treatments are often essential, but the high costs are often not sustainable for individuals, families, or for the U.S. healthcare system.

Why do Cancer Treatment Costs Continue to Rise at Astronomical Rates?

Pharmaceutical companies, physician practices, and cancer screenings all play a role in the rising costs of treating cancer patients.  The treatment costs could be reduced, however.  Fortunately, there are now a variety of treatment options from which most patients can choose.  One problem is that pharmaceutical companies tend to charge higher prices for their new drugs; for example, Provenge, used to fight prostate cancer, is $93,000 for just one course of treatment.[4] Avastin typically costs stage 4 breast cancer patients more than $80,000, but the latest research indicates that for most patients it does not increase survival and is likely to harm quality of life.[5,6] Some cancer medications range from $5,000 to $10,000 per month, which over several years really adds up.[7] Many of these new drugs work for relatively few people, while most patients pay thousands of dollars and do not benefit or may even be harmed.  The companies have no incentive to determine which patients are most likely to benefit, if they can instead sell the drugs to most patients, including those who won’t benefit.  That leaves doctors and patients trying many expensive treatments until they find one that works for each individual.  Insurance companies, Medicare, and sometimes the individual must pay these exorbitant costs during this trial and error treatment.

Another factor that contributes to the high cost of cancer treatments can be a physician’s own treatment recommendations.  Physicians are there to help their patients, but research has shown that physicians who have financial ties to specific companies tend to recommend medical products made by those companies.[8,9] Many patients also rely on Medicare, which is not allowed to deny or limit cancer treatment based on cost.  As a result, Medicare patients and their doctors often have no incentive to choose equally effective but less expensive medications and treatments.[10,11] Doctors and patients also have little incentive to question high-priced treatments.[12] Unfortunately, physicians frequently do not adhere to evidence-based guidelines, leading them to sometimes prescribe and perform tests that may be more expensive than beneficial to patients.[13]

Cancer costs can add up-even before cancer is actually diagnosed.  Cancer screenings are designed to increase the number of patients who are diagnosed early, before they have any symptoms. When performed according to recommended guidelines, screening can help patients get a much earlier start on treatment. However, cancer screening tests often identify abnormalities that may or may not be cancer, which can result in expensive testing, unnecessary treatment, and added costs.  These costs can’t always be avoided, but they are increased when screening guidelines are not followed.  For example, a 2011 study found that a large number of elderly men were being screened for prostate cancer even though they were beyond the target age range for testing.[14] Prostate cancer screening tests can cause serious harm, exposing men to unnecessary treatments as well as unnecessary costs.  Similar results have been found for cervical cancer screening in women.  Certain types of HPV (Human Papillomavirus) have been linked to cervical cancer, so physicians like to determine the type of HPV as a method to screen for cervical cancer.  Unfortunately, a Center for Disease Control (CDC) study found that physicians are performing unnecessary and expensive routine HPV tests.[15] When HPV tests were initially developed, two types of tests were run together: one to detect HPVs that can cause cancer, and one for HPVs that don’t cause cancer.  However, now that an HPV test that focuses only on cancer-causing HPV has been available, that is the only HPV test recommended for physicians to use.  This recommended test should only be done for women over 21 who have inconclusive pap smear results, or women over 30 who are undergoing pap smears. The problem is that many physicians and clinics are using the cervical cancer HPV test routinely for all patients, or are using both the recommended HPV test and the non-recommended test for non-cancerous HPV; either of these inappropriate uses results in a doubling of medical bills, without any additional benefit to the patient.[16] Screening mammograms for women above or below the recommended age range, or given more frequently than recommended, also result in unnecessary anxiety, treatment, and medical expenses, which outweigh the benefits for most women.[17]

Is There Any Way to Reduce These Costs?

The skyrocketing cost of cancer treatments has brought the issue to public attention, as politicians, doctors, and organizations speak out about ways that we can work together to reduce these costs   Dr. Howard Brody’s “Call to Action” in the New England Journal of Medicine challenged physicians to name five high-priced treatments that are commonly used in practice, but have not been shown to be highly effective in patients.  He pointed out that if physicians can exchange these practices for low-cost, more effective treatments, a small dent could be made in rising healthcare costs.[18] Two oncologists responded to Brody’s request with five ways to reduce costs for cancer treatments.  They include using imaging and tests only where benefits to patients have been shown, limiting chemotherapy for people that are very weak and would not benefit from this additional treatment, and a greater coordination of care.  Additionally, they suggest an increased focus on palliative care, which has been found to make patients more comfortable, have better health outcomes, and reduce the number of costly and often ineffective treatments tried during the patient’s final months.[19,20]

To combat the rising costs of medications and medical devices, the 2010 health care reform law encourages more comparative effectiveness research through the formation of a non-profit Patient Centered Outcomes Research Institute.[21] This institute will help ensure that new medical treatments are studied to determine if they are better or worse than ones already on the market.  Similarly, two researchers are proposing a new type of regulation called “reference pricing” to ensure that patients are getting more out of these new treatments.  Reference pricing would require that medical products paid for by Medicare be tested to compare them to similar products that are already on the market. The companies would have 3 years to prove that their new product is better than the ones already on the market. If tests do not show that the product is safer or more effective, it could not be sold at a higher price than the older products on the market.  While reference pricing is not required as part of the health care reform law, it could be used as a strategy under the law to encourage medical product manufacturers to finance comparative effectiveness research.[22]

Changing physician and pharmaceutical company practices might seem like a daunting task, but there are some small steps that you as an individual can do to help lower costs associated with cancer treatments.  It is important that you discuss your financial and medical situation with your doctor. Make sure that you fully understand your illness and make sure your doctor fully understands your financial situation.  In some cases, your doctor may be able to prescribe less expensive, but just as effective, drug treatments that could save you money.[23] Additionally, it is important to talk to your doctor about regular cancer screenings and your family’s history of certain cancers or diseases.  You might be in the target age-range or at risk for other reasons that meet the standards of some screenings, but not for others.  This will help to maximize the benefits you will receive from these health screenings and help to eliminate unnecessary costs or treatments.[24]

Patients deserve a high standard of quality of care. Fortunately, it is possible to lower costs while maintaining or even improving the quality of care. We can do this with unbiased research to determine which treatments are most effective and by creating regulatory methods to ensure that the cost of medications must reflect their effectiveness.

If you or a loved one has been diagnosed with cancer and would like to learn about financial assistance options, please visit The National Cancer Institute (NCI) web site https://www.cancer.gov/about-cancer/managing-care/track-care-costs.  They offer a wide variety of resources to help with cancer treatment costs for those with and without health insurance.

References:

  1. National Cancer Institute, NIH, DHHS (2010) Cancer Trends Progress Report – 2009/2010 Update, Bethesda, MD, http://progressreport.cancer.gov.
  2. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, and Brown ML. (2011). Projections of the Cost of Cancer Care in the United States: 2010-2020., Journal of the National Cancer Institute 103(2). Retrieved from http://jnci.oxfordjournals.org/content/103/2/NP.2.full
  3. USA Today/Kaiser Family Foundation/Harvard School of Public Health National Survey of Households Affected by Cancer. November 20, 2009.http://www.kff.org/kaiserpolls/pomr112006pkg.cfm. Accessed February 10, 2010
  4.  No Author, (2011) The costly war on cancer. The Economist. Retrieved from http://www.economist.com/node/18743951
  5. Twombly, R. (2011). Avastin’s uncertain future in breast cancer treatment . Journal of the National Cancer Institute, 103(6), Retrieved from http://jnci.oxfordjournals.org/content/103/6/458.full
  6. Ranpura, V, Hapani, S, and Wu, S. (2011). Treatment-related mortality with bevacizumab in cancer patients. The Journal of the American Medical Association, 305(5), Retrieved from http://jama.ama-assn.org/content/305/5/487.full
  7. Goozner, M. (2011) Health care reform: Prove it works and CMS will pay. The Fiscal Times. Retrieved from http://www.thefiscaltimes.com/Articles/2010/10/05/Health-Care-Reform-CMS-Wants-Proof-to-Pay.aspx
  8. Elkin EB and Bach PB (2010). Cancer’s next frontier: Addressing high and increasing costs. The Journal of the American Medical Association, 303(24). Retrieved from http://jama.ama-assn.org/content/303/11/1086.short?home
  9. Jost, TS. (2010). Oversight of marketing relationships between physicians and the drug and device industry: a comparative study. American Journal of Law and Medicine, 36. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20726399
  10. Weight, CJ, Klien, EA, and Jones, JS. (2008). Androgen deprivation falls as orchiectomy rates rise after changes in reimbursement in the U.S. Medicare population. Cancer, 112(10), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18393326
  11. Goozner, M. (2011) Health care reform: Prove it works and CMS will pay. The Fiscal Times. Retrieved from http://www.thefiscaltimes.com/Articles/2010/10/05/Health-Care-Reform-CMS-Wants-Proof-to-Pay.aspx
  12. No Author, (2011) The costly war on cancer. The Economist. Retrieved from http://www.economist.com/node/18743951
  13. Brody, H. (2009). Medicine’s ethical responsibility for health care reform – the top five list. New England Journal of Medicine. Retrieved from http://healthpolicyandreform.nejm.org/?p=2616
  14. American Society of Clinical Oncology (2011). Many elderly men are undergoing unnecessary PSA screenings, researchers find. ScienceDaily. Retrieved June 20, 2011, from http://www.sciencedaily.com­/releases/2011/03/110328161848.htm
  15. Lee, JW, Berkowitz, Z, and Saraiya, M. (2011). Low-risk human papillomavirus testing and other nonrecommended human papillomavirus testing practices among U.S. health care providers. Obstetrics & Gynecology, 118(1), doi: 10.1097/AOG.0b013e3182210034
  16. Lee, JW, Berkowitz, Z, and Saraiya, M. (2011). Low-risk human papillomavirus testing and other nonrecommended human papillomavirus testing practices among U.S. health care providers. Obstetrics & Gynecology, 118(1), doi: 10.1097/AOG.0b013e3182210034
  17. Quanstrum, KH and Hayward, RA. (2010). Lessons from the mammography wars. New England Journal of Medicine, 363. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsb1002538
  18. Brody, H. (2009). Medicine’s ethical responsibility for health care reform – the top five list. New England Journal of Medicine. Retrieved from http://healthpolicyandreform.nejm.org/?p=2616
  19. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, and Brown ML. (2011). Projections of the Cost of Cancer Care in the United States: 2010-2020., Journal of the National Cancer Institute 103(2). Retrieved from http://jnci.oxfordjournals.org/content/103/2/NP.2.full
  20. Smith TJ and Hillner BE. (2011). Bending the cost curve in cancer care. New England Journal of Medicine. Retrieved from http://healthpolicyandreform.nejm.org/?p=14541&query=home
  21. Kaiser Family Foundation. (2011, April 19). Summary of new health reform law. Retrieved from http://www.kff.org/healthreform/8061.cfm
  22. Goozner, M. (2011) Health care reform: Prove it works and CMS will pay. The Fiscal Times. Retrieved from http://www.thefiscaltimes.com/Articles/2010/10/05/Health-Care-Reform-CMS-Wants-Proof-to-Pay.aspx
  23. Consumers Union of U.S. (2009, March). 10 ways to reduce your drug costs. Retrieved from http://www.consumerreports.org/health/prescription-drugs/10-ways-to-reduce-your-drug-costs/overview/10-ways-to-reduce-your-drug-costs.htm
  24. Quanstrum, KH, and Hayward, RA. (2010). Lessons from the mammography wars. New England Journal of Medicine, 363. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsb1002538

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Cancer Researchers with Industry Ties Report “Rosier” Results

Stephanie Portes-Antoine and Brandel France de Bravo, MPH, Cancer Prevention and Treatment Fund

With all of the cancer studies being performed today, how can consumers be sure of their accuracy? A study by Dr. Reshma Jagsi at the University of Michigan and her colleagues indicates that cancer studies are more likely to have positive results when the researchers have ties to the company that makes the product being studied.[1]

This study focused on cancer research articles published in eight medical journals, including Cancer, the Journal of the National Cancer Institute, the New England Journal of Medicine, the Journal of the American Medical Association, and the Lancet. An author was categorized as having a conflict of interest if he or she reported one or was employed, at the time of publication, by the company that makes the medical product being studied, or if a drug or medical device manufacturer was a source of funding for the study. Dr. Jagsi and colleagues relied exclusively on disclosures and information given in the articles themselves. They did no further investigation into authors’ financial ties to industry such as checking board memberships or employee listings. For this reason, the authors believe that their findings may underestimate the extent and effects of conflicts of interest in cancer research.

The authors reviewed 1,534 articles on cancer studies published in 2006. Twelve percent of the articles included at least one author employed by industry—a company that makes medical products—and 17% of articles declared industry funding. The articles most likely to have conflicts of interest included those with authors from medical oncology departments; articles from North America; and articles where the first or last author was a man (these are most likely to be the senior author or principle investigator).  Studies having to do with diagnostic radiology were least likely to have conflicts, whereas those involving prostate, lung, skin, and hematologic (blood-related) cancer were most likely to have conflicts.

Nearly one-quarter of the articles disclosed a conflict of interest. By looking at funding sources and author affiliations, Dr. Jagsi and colleagues concluded that 29% of articles had an apparent conflict of interest, meaning that disclosures do not tell the whole story. This discrepancy can be due to many factors: some journals may have chosen to omit certain information in the disclosures; different journals have different guidelines and policies on disclosure; and cultural norms regarding disclosure vary from one region of the world to another.

 

Cancer studies with conflict
Industry funding of study
17%
Industry employee
12%
Consulting
12%
Industry funding of other research by author
11%
Honoraria
9%
Stock
8%
Lecture fees
3%
Corporate board
3%
Industry-supplied drugs or technology
2%
Testimony/legal team
1%
Patent
1%

Source: “Frequency, Nature, Effects, and Correlates of Conflicts of Interest in Published Clinical Cancer Research,” Cancer. 2009; 115:2783-2791. Table in this form reproduced from: http://www.ama-assn.org/amednews/2009/05/25/prsa0525.htm

Industry-funded studies were far more likely to focus on treatment than non-industry funded studies (62% vs. 36%) and much less likely to look at epidemiology, risk factors, and effective means of disease prevention and diagnosis (20% vs. 47%).

Randomized clinical trials were more likely to find that a treatment or intervention improved patient survival if a conflict of interest was present. Dr. Jagsi and his co-authors suggest that several factors may account for this. Industry-funded research may tend to design studies that are likely to show their products are effective. The example they give is trials where a drug is tested against a placebo rather than against a drug already in use. Also, journals may be more interested in publishing positive results, which would inadvertently favor studies whose authors have conflicts of interest.

Since randomized clinical trials are the gold standard for the adoption of new therapies and technologies, these conflicts of interest or “funder effects” have serious implications for cancer treatment and public health. Even if industry funding does not lead researchers to exaggerate a treatment or product’s benefits, studies have indicated that they may tend to not publish negative findings. For example, an analysis of 44 studies on the cost-effectiveness of new oncology drugs found that those sponsored by industry were less likely to conclude that a drug was not cost-effective than studies funded by agencies or institutions without a profit incentive, such as government or university-funded studies.[2] In fact, the industry-funded studies were eight times less likely to assess a drug unfavorably than non-industry studies.

Studies dating back as far as 1986 have shown that clinical trials funded by industry are far more likely to favor new therapies over traditional ones.[3] New therapies usually cost more, and usually less is known about their potential risks.

Medical researchers often rely on industry funding, and this is true for cancer researchers. In a study published in 2013, Dr. Francisco Emilio Vera-Badillo and colleagues at the University of Toronto found that 63% of the breast cancer studies they looked at were funded by industry, but they did not find that the results of the studies necessarily favored the companies that paid for them.[4] Other studies, however, indicate that industry funding affects not only the way results are reported but the type of research that is carried out. This is why it is important that medical research—which is for the benefit of all, not just those who manufacture drugs and other therapies—receive funding from diverse sources, including those without a profit incentive. Since the new research indicates that not all conflicts of interest are acknowledged in medical publications, journals should implement stricter policies regarding accurate disclosure of potential conflicts of interest. In addition, peer reviewers and editors should scrutinize the study design and data analyses carefully and ask tough questions of authors to ensure the accuracy of the findings and conclusions. These efforts are especially crucial when the studies involve treatment for potentially fatal diseases such as cancer.

For information on the misrepresentation of effectiveness and side effects of cancer treatments, click here.

References:

  1. Jagsi R, Sheets N, Jankovic A, Motomura AR, Amarnath S, Ubel PA. Frequency, nature, effects, and correlates of conflict of interest in published clinical cancer research. Cancer. 2009;115: 2783-2791.
  2. Friedberg M, Saffran B, Stinson TJ, Nelson W, Bennett CL.. Evaluation of conflict of interest in economic analyses of new drugs used in oncology. Journal of the American Medical Association. 1999; 282: 1453-1457
  3. Davidson RA. Source of funding and outcome of clinical trials. Journal of General Internal Medicine. 1986; 1:155-158.
  4. Vera-Badillo, FE, Shapiro, R, Ocana, A, Amir, E, Tannock, IF. Bias in reporting of endpoints of efficacy and toxicity in randomized, clinical trials for women with breast cancer. Annals of Oncology. 2013; 00: 1-6.