The Daily Mail has reported that doctors do not support giving life-extending drugs to patients with terminal cancer. The newspaper says that a new report has said the treatments “give false hope and are too costly for the public purse”.
The news story is based on an extensive international report that examined the cost and value of cancer care in developed countries. In the report doctors, health economists and patient advocates voice their opinions and suggest potential policy changes that could make cancer care more affordable for both patients and society. However, the report does not actually suggest that life-extending drugs should be withheld from terminal cancer patients, rather that there is a greater need to understand whether treatments at this stage will actually extend life, and whether resources would be better directed at improving patients’ quality of life through options such as palliative care. The report also suggests several policy areas that could be targeted to improve quality of care while reducing its cost.
This report is likely to stimulate discussions on policy relating to cancer care, but it is not policy itself. The report is of great interest but a broad agreement within the health service would be needed if it were to change the manner in which care is provided in the UK.
Where did the story come from?
The report was created by researchers from a variety of institutions from the UK, US, Australia, Canada and across Europe. These institutions include King’s College London, CancerPartnersUK, North of England Cancer Network, Northumbria Healthcare, the Institute of Nuclear Medicine, the Association of the British Pharmaceutical Industry, the University of London and Oxford University.
The commission was funded by the Conquer Cancer Foundation and the Greenwall Foundation for Bioethics, the University of California Los Angeles, Belgium’s Herculesstichting and Fonds voor Wetenschappelijk Onderzoek-Vlaanderen, and the UK’s National Institute for Health Research (NIHR) Biomedical Research Centre and Department of Health.
The study was published in the journal The Lancet Oncology. However, it was published as an opinion piece and was not subject to the peer-review process.
The media focused on futile care, which is a particular issue highlighted in the report. This is addressed under the issue of ‘overutilisation’ in general, and is not the primary focus of the report. That said, the report does recommend that special attention should be paid to end of life cancer care. They say that improving the ability to predict the effectiveness of treatment could spare patients side effects and false hope from ineffective care, and also spare the healthcare system the cost of ineffective care. However, some life-extending drugs are valuable for people with terminal illness and the authors do not say that all of these give false hope or are too expensive.
What kind of research was this?
This is a discursive policy report written by a panel of international cancer experts. The report is intended to guide public debate on cancer care in developed countries, including the UK. The report attempts to identify the drivers of high-cost cancer care, as well as to propose solutions for these issues.
The extensive report looks at many of the different factors that drive the cost of cancer care. It gathers opinions from a variety of experts, including clinicians, patient advocates, policy makers and cancer survivors. The authors examined the cost and effectiveness of cancer care, and identified issues that drive up the cost of care but that may not provide great improvements in health outcomes. Among the issues examined are the economics of cancer care, the individual and societal impact of cancer treatments, areas where new technology could be improved or developed, predicted rates of cancer in the years to come and whether current methods for evaluating evidence are appropriate.
What did the research involve?
The authors collected opinions from a wide variety of experts on the status of cancer care costs and the effectiveness of cancer treatment in developed countries. They examined the role that cost drivers, evolving patterns of disease and trends in the provision of care play in determining the amount of money spent on cancer care. They then examined the value of cancer care from various perspectives, including the role played by:
- health research and research into cost-effectiveness
- available treatment options, such as surgery, radiation and imaging technologies
- the possibilities offered by new testing technologies, including genetic testing
- anti-cancer drugs, the pharmaceutical industry and the processes for developing new drugs
- patients’ involvement in treatment and their ability to express their wishes
They also examined current approaches to addressing the affordability of cancer care in different countries.
The authors say that there are several areas that could be addressed to reduce cost and improve the quality of cancer care. These are as follows.
Cost of care
The authors first examined the cost of cancer care, and specifically ‘cost drivers’. These are those interventions that account for most of the costs. They examined the cost of cancer from the perspective not only of the price paid for treatments, but also in terms of the economic impact of patients not being able to function normally due to illness or early death.
Burden of disease
The authors also looked at the patterns of disease, the complexity of illness and how research accounted for these patterns. They then examined how this burden of disease translates into the cost of treating individual patients and the cost of treating cancer in society as a whole.
The authors next highlight the process by which technologies are developed and the cost of this process, and suggest ways in which these costs could be reduced without forfeiting benefits in terms of health outcomes.
The report looks at how ‘overutilisation’ of cancer technologies and services can drive costs without adding any additional benefit in terms of health outcomes, for example the use of expensive diagnostic tests that provide no greater benefit than cheaper alternatives. The authors identified areas of care that could be reduced without reducing health outcomes.
What were the basic results?
The study is extensive so the following section only provides a very brief overview of its findings. The authors identified multiple sources of high cancer costs, and outlined recommendations for improving care and reducing costs in each of the identified areas.
Cost of care
The authors found that the absolute amount spent on cancer care is increasing in all developed countries, and that the rate of this increase is going up year by year. They say that this is not simply due to the increasing number of cancer cases seen, but that the rise is also driven by factors such as the use of increasingly individualised treatments that are expensive to develop and the use of inappropriate cancer products (although they say this is more of an issue in the US than in the UK). They found that in 2009-2010, the NHS spent £5.86 billion on cancer care, which is 5.6% of the UK’s total health spend.
They recommend that countries attempt to drive the development of new low-cost technologies by increasing the use of off-patent products and rethinking the pathway of care that patients follow when they have cancer.
Burden of disease
The report says that one of the main drivers of cancer care costs is the ageing population (more people are being diagnosed with cancer) and the increasing complexity of disease, including patients with multiple illnesses. They say that the increase in cancer care costs is due both to the amount spent per patient and the number of patients diagnosed.
The authors found that current clinical research often fails accurately to reflect the burden of disease seen in the real world. Patients with multiple illnesses are often excluded from clinical trials, so that the evidence base for new technologies does not accurately reflect the way in which cancer occurs and will be treated in the real world. The researchers recommend that clinical research into new treatments be reflective of this real-world burden of disease for society, and take into account patient frailty and multiple illnesses.
The authors found that many technologies that provide little additional benefit are taken all the way through the technology development phase, which becomes increasingly expensive the further along it goes. They recommend that the technology development process be changed, and that the design of early clinical trials be improved. They say that technologies that show little additional benefit should be halted earlier in the development process so that they do not reach the most expensive phases. The researchers say that this should result not only in reduced research costs, but also in more rigorous standards of evidence.
The report found that overutilisation of cancer services is an issue in all areas of care. The authors say that the need to treat cancer promptly plays a role in overutilisation as it may be quicker and easier for medical staff to discuss a plan for treatment than to discuss why other treatments may not be suitable for use. They say that clinicians are also increasingly relying on technology and scans to assess new symptoms rather than physical examinations, but that the costs of using imaging techniques are also increasing per patient. The sheer amount of information on new technologies may also prevent clinicians from thoroughly understanding the evidence base needed to decide on the most appropriate treatment plan for a patient.
The report recommends six indicators of when interventions may be suitable for reduction, where cutting the use would have minimal effect on health outcomes. These include interventions that:
- provide no benefit
- result in little increased benefit
- have no clearly defined benefit
- are not desired by patients
- are duplicates of other tests or services
- are more expensive than an equally effective alternative treatment
How did the researchers interpret the results?
The authors say that “in general, there are two primary mechanisms to control costs. We can lower the cost of cancer-care services or interventions, or we can reduce [their use]”. They say that examining current policy can result in decreased utilisation of ineffective services, and increased utilisation of effective services. This, they say, is the way to improve efficiency and value of cancer care. They further say that rethinking how research, policy and clinical practice interact can result in reduced costs and improved quality of cancer care.
This is an extensive expert opinion piece looking at the high cost of cancer care. The authors examined cost drivers from a variety of policy and clinical perspectives – from epidemiology to research to technology development and health economics. The report identifies key areas that they feel could be addressed to reduce the cost and improve the quality of cancer care. Although the paper discusses specific treatments and national healthcare systems (including the NHS) it is not a specific analysis of where changes in individual systems would be beneficial. Instead, the document raises many issues pertaining to whether cancer care strategies need to be examined and reformed in terms of both cost-effectiveness and clinical benefit.
However, the media generally focused on one specific recommendation outlined in the report - the suggestion that attempts to use cancer-fighting therapies to lengthen the lives of terminal-stage cancer patients may not always be appropriate. Newspaper coverage may not fully reflect the tone and context of the report, which arguably raises questions on the issue rather than attempting to provide a definitive verdict on the current situation.
For example, rather than suggesting that medical care should be withdrawn from cancer patients within their last few weeks of life, the report says that continuing care strategies such as chemotherapy may be problematic for patients, and that focusing on palliative care may improve their quality of life and possibly prolong their survival. In short, the researchers question whether spending could be directed at cheaper, potentially better methods for helping people with late-stage cancer, and (contrary to some news coverage) do not suggest that they should not be helped at all.
The researchers also suggest that there is a need for clinical measures that can accurately determine which late-stage patients would and would not benefit from further disease-fighting therapy, highlighting that they are not advocating the withdrawal of appropriate care options for terminal patients.
The authors say that each health system now needs to consider how much is spent on cancer care and prevention compared with other healthcare priorities. This should include funding the most effective interventions, and insistence on a strong evidence base before adopting newly available medical technology.
The authors say that focusing on areas of care that provide little or no benefit, increasing the use of low-cost technologies and refocusing care pathways on high-quality, cost-effective and value-based care can reduce the cost of cancer care without sacrificing benefits. They also say that countries could further address cancer care costs by developing new ways of financing cancer care, including evaluating the pricing of drugs.
Overall, this is a valuable and intriguing exploration of the nature of current cancer treatment and, contrary to the impression given by media reports, these authors do not suggest that all end of life care should be stopped. Instead the report focuses on value, saying that the benefits of cancer care should be weighed from both an individual and societal perspective, and that the cost of care, in terms of price as well as side effects, should be balanced against the benefits, including quality as well as extension of life.
Links to the headlines
Dying cancer patients should not be given 'futile' drugs. The Daily Telegraph, September 27 2011
Don't give out cancer drugs if it's just to extend life: Treatment costs can't be justified, say experts. Daily Mail, September 27 2011
Cancer cost 'crisis' warning from oncologists. BBC News, September 27 2011
Links to the science
Sullivan R, Peppercorn J, Sikora K et al. Delivering affordable cancer care in high-income countries. The Lancet Oncology, Volume 12, Issue 10, Pages 933 - 980, September 2011
Thursday, September 29, 2011
Use of cancer drugs questioned - Health News - NHS Choices