Should oncologists discuss the cost of treatment with patients?

Having cost conversations will be a big change.

The cost discussion is very hard. In many ways, it goes against our training as physicians, which is to not think about costs as we consider what is best for our patients. It is a bit of a mindset change to say ‘I’m going to think about the cost implications of my treatment recommendations.’ It is changing, but that is kind of foreign to the way we’re taught to think about caring for our patient’s approach. I often talk about the burdens of the treatment in terms of the effects on the patient independent of cost, rather than saying that I don’t think a treatment is worth the cost.

It’s going to be a hard sell to say we’re going to have a cost conversation with individual patients. It may be that those decisions will be made further up the chain in the public health arena, rather than at the individual level. That would be very hard to inject into the doctor-patient relationship.

Doctors will be involved in the process, but I don’t think it’s a conversation that will happen at the individual patient level. It will happen with doctors higher up. The hospital board or the practice board or even at the local/state/national level doctors will have input in these high-level decisions about what’s going to be covered or not covered.

I really don’t think it’s going to happen at the individual level. That just cuts too much against what doctors do. They feel comfortable saying, ‘As a group, this is how we treat your type of disease,’ not ‘For you in particular, you can’t afford this so we’re not going to offer it.’

There will be guidelines that say, ‘Here’s the circumstance by which this treatment is justified.’ Even if the basis is primarily cost, ‘We’re not going to pay for this very expensive therapy for anyone with this kind of disease because we don’t think it helps enough, it’s very expensive and we can’t provide less expensive therapies to other groups of patients.’ That decision could be made at the hospital level, the group practice level, the state level or the national level as NICE does in the British system. The guidelines would say something like, ‘When you talk to individual patients, these are our policies.’

I don’t think if you leave those things on the formulary and let the doctors sort it out on the individual level we’re going to make much progress. It’s too hard to expect the doctor to withhold therapy because he thinks it’s too expensive.

William Dale, MD, PhD, is Chief of Geriatrics and Palliative Care Medicine at the University of Chicago Medical Center. He is the Director of the Specialized Oncology Care and Research in the Elderly (SOCARE) clinic.

Cost conversations are not the job of the treating physician.

Oncologists don’t have that discussion, and that is largely because in a majority of cases a third party is paying. Also, most oncologists would rather not address it. Their feeling is, ‘That should have been taken care of by someone else. I just should be charged with administering to the patient the best care available.’ They feel that is in the purview of someone other than the primary physician.

I think that’s right. It is the purview of pharmaceutical companies, large associations such as ASCO and to some extent the FDA. Most primary care physicians would say, ‘My job is to provide the very best care and the price issues should be handled somewhere else.’

Now, should we say to a patient that a drug has very limited effectiveness and it’s going to be very costly? You could say that, but most patients, in reality, don’t see it as an out-of-pocket expense. Most people think that if a treatment has a chance of helping, it’s probably worth it. That’s the way things have evolved in the United States. It would take a change in our culture for cost to become part of the conversation.

Oncologists think about affordability when the patient doesn’t have insurance or has limited coverage. In those cases, cost does factor in. We may not want to think there is a two-tier system, but it probably does factor in. However, I don’t think it affects patient care. At the end of the day, physicians do what they think is in the patient’s best interest.

If, however, you’re going to give bevacizumab (Avastin, Genetech) or cetuximab (Erbitux, ImClone Systems) for a type of cancer where the drug isn’t proven, it’s just as likely to work as ‘metronomic’ schedule of cytoxin. If one were to do a study, one would find that it’s just as likely that one works as the other, but the fractional cost is 1,000-fold less for the metronomic cytoxin as the bevacizumab or cetuximab. As physicians, in order to help patients continue to fight, we do have options that are less expensive than some of the ones we use.

Tito Fojo, MD, PhD, is head of the Experimental Therapeutics Section at the National Cancer Institute.