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The value proposition in oncology: ASCO and ESMO bite the bullet
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It is a disturbing fact that the costs of health care are spiraling upwards, and that an exemplar of this troubling trend is the domain of oncology treatment and research.
By 2020, it is projected that cancer care will cost more than $150 billion in the United States. Although this represents only a relatively small fraction of total health care costs, cancer care is escalating more rapidly than most other specialties.
Many factors contribute to this unhappy situation. They include the aging of the population; persistence of risk-taking by the community at large (smoking, excessive sun exposure and lack of attention to industrial pollution, to name a few); increasingly expensive research, diagnostic tests, surgical approaches, radiotherapy techniques and novel systemic therapies; and some unrealistic expectations of patients, families and the community at large (often predicated on false claims from our profession and/or hype from the Fourth Estate).
ASCO has recognized this set of problems, and for several years has attempted to address some of the contributing factors, including participation in the Institute of Medicine’s Choosing Wisely campaign, the development of certification and quality assurance programs, and the establishment of the Value in Cancer Care Task Force. Truth in disclosure, I have been a member of this task force — ably led by Lowell E. Schnipper, MD — for several years, and thus have some conflict of interest in discussing the present topic.
In the Aug. 10 edition of Journal of Clinical Oncology, preceded by online publication in June, Schnipper and members of the task force — as well as some ASCO dignitaries — published a paper titled “American Society of Clinical Oncology Statement: A conceptual framework to assess the value of cancer treatment options.”
I have to confess that this is a tough paper to read, but the topic is crucially important, and it has to be worth the effort. I encourage you to read this important manuscript carefully.
Determination of value
In principle, the task force has attempted to create a mathematical algorithm to attribute value points for the use of systemic therapy in cancer care. The basic construct is as follows:
Two major contextual categories are created — advanced disease (eg, treatment for metastases) and curative intent (eg, adjuvant therapy).
Clinical benefit is given a score of 1 to 5, and then numerical weightings are added to reflect the impact of treatment on OS, PFS or response rate. The weightings reflect the thought that OS is more important than PFS, which is more important than response rate when attempting to attribute value for the patient. Negative scores are added to reflect the extent of toxicity.
In the setting of advanced disease, bonus points are awarded for palliation of symptoms and for longer treatment-free intervals. Finally, the cost of treatment is listed to broaden the context.
In the adjuvant setting, instead of the response–survival parameters above, HR is incorporated into the algorithm and disease-free interval is substituted, but with a slightly lower weighting.
The overall construct of net health benefit is incorporated to allow the patient to attribute likely value to the treatment, balancing benefit(s) and toxicities.
‘Noble first efforts’
Unbeknownst to the ASCO task force, the European Society for Medical Oncology (ESMO) had created a similar task force to work on its own statement on the value proposition in oncology — the ESMO Magnitude of Clinical Benefit Scale.
The position paper from that task force — led by Nathan I. Cherny, MBBS, FRACP, FRCP — was published in August in Annals of Oncology.
What is quite remarkable is the extraordinary similarity — in concept and execution — achieved by two committees working in the United States and in Europe, both without knowledge of the work in progress of the other team.
The ESMO team also has focused on separate domains of curative and palliative settings, and attributed levels of benefit predicated on absolute or relative increments in survival and levels of toxicity. Of importance, they have set time-dependent criteria, such that the value points allocated for absolute survival increments differ for those with sustained increases vs. patients with only short-term increments in survival.
Interestingly, both committees used similar sets of level one data to develop their models and came to quite similar interpretations of value, notwithstanding different community pressures, health care costs and medical traditions on different sides of the Atlantic.
These efforts are important and represent crucial first steps by members of our profession in attempting to increase the level of self-discipline and value-based self-criticism of what we do, and increased transparency in what we tell our patients about the benefits gleaned from our ministrations.
I would have preferred a higher bar with regard to attribution of value points. I certainly recognize that someone with a prognosis measured in 3 to 6 months will sustain greater benefit from a 2-month increment than someone treated with curative or aggressive palliative intent; however, 2 months is dreadfully short, and it worries me when we make too much of an HR of 60% when the absolute time increment is so short.
Nonetheless, these are noble first efforts and should be respected as such. They deserve careful and critical attention and feedback, as this type of work will define the future of oncology practice and the welfare of our patients.
References:
Cherny NI, et al. Ann Oncol. 2015;doi:10.1093/annonc/mdv249.
Schnipper LE, et al. J Clin Oncol. 2015;doi:10.1200/JCO.2015.61.6706.
For more information:
Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.
Disclosure: Raghavan reports no relevant financial disclosures.