Lung cancer treatments may not be cost-effective

Spending on treatment in the United States has risen but survival has not improved.

Issue: December 1, 2007

Although the treatment of lung cancer has become more expensive, patient survival has not improved.

Rebecca M. Woodward, PhD, a researcher with the National Bureau of Economic Research and a former research associate at the Harvard Interfaculty Program of Health Systems Improvement, and colleagues conducted a study to determine the effect of spending for non–small cell lung cancer treatment among the elderly.

“Some spending to treat certain diseases, such as heart disease, has already been shown to have an overwhelming return in terms of gains in life expectancy. The return on investment in spending on lung cancer medical treatment is less promising,” Woodward said.

The researchers used Surveillance, Epidemiology, and End Results trial data to calculate life expectancy after diagnosis between 1983 and 1997. The researchers combined these data with data found in the Continuous Medicare History Sample File to calculate lifetime treatment costs.

Life expectancy minimally improved, with an average increase of approximately 0.6 months. Total lifetime lung cancer spending rose by $20,157 per patient from the early 1980s to the mid-1990s, for a cost-effectiveness ratio of $403,142 per life-year. The cost-effectiveness ratio was $143,614 for localized cancer, $145,861 for regional cancer and $1,190,322 for metastatic cancer.

The researchers reached three main conclusions. First, spending on lung cancer has increased greatly relative to the economy but not more than spending on other diseases. Second, almost all gains in survival have been in localized cancer cases. Third, the costs per additional year of life were high.

“The most surprising result from our study was that it was less expensive to have lung cancer than to not have lung cancer and die of another disease. Part of the explanation for this is that end-of-life costs for the general population more than doubled in this period, whereas there was a less dramatic increase in end-of-life costs for the patients with lung cancer,” Woodward said.

Treating patients

The researchers said the treatment of lung cancer should be reevaluated. “Given the number of patients affected and dollar values involved, a clear analysis and frank discussion of what has transpired in the big picture of cancer care is necessary to establish the background for our medical, political and economic discussions. Our results indicate that marked improvement has not occurred to date in the case of spending on non–small cell lung cancer treatment for those aged 65 and older,” Woodward said.

Given that tobacco smoking accounts for most lung cancer cases, smoking prevention and cessation are perhaps more promising, according to Woodward.

Proceed with caution

The researchers said caution should be used before encouraging more intensive care for patients with lung cancer without considering the trade-offs with the costs of therapy and its potential effects on mortality and quality of life.

Joseph Aisner, MD, chief medical officer at the Cancer Institute of New Jersey and lung cancer section editor for Hem/Onc Today, said that although the findings are interesting, the researchers were not selective about who should be treated, and they relied on outcome data from a prior decade.

“What needs to be identified is who is most likely to benefit from treatment in terms of both quality and quantity of survival. The first question is therefore who should be treated, not how much does it cost. Furthermore, treatment and supportive care have dramatically improved, as witnessed by arriving at second- and third-line treatments,” Aisner told Hem/Onc Today.

Aisner said experts have long known that performance status and weight loss are the two most powerful predictors of outcome within stage, both predicting toxicity and poor survival. Including such patients, regardless of whether they should have been included in a trial, will not give an accurate impression of benefit. Thus, these factors must be considered when evaluating treatment outcomes.

Several trials have shown that “fit” elderly can do well and can tolerate doublet treatments. Thus in the elderly population, “fitness,” like performance status and weight loss, should be evaluated rather than age. Given that the paradigms for treatment have shifted in the last decade, and some patients are now alive at two and three years, the relevance of the Woodward study is limited, according to Aisner.

In future studies, Woodward would like to see better measurement of quality of life. “We know that quality of life is an important treatment effect and is thus an important potential benefit of our spending on medical treatment,” Woodward said. – by Brandy Brinson

For more information:

Woodward RM, Brown ML, Stewart ST, et al. The value of medical interventions for lung cancer in the elderly. Cancer. 2007;doi:10.1002/cncr23058. Accessed Nov. 5, 2007.