National Cancer Institute NCI Cancer Bulletin: A Trusted Source for Cancer Research News
July 14, 2009 • Volume 6 / Number 14

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Featured Article

Cancer Doctors Urged to Discuss Treatment Costs with Patients

Clinician/patient discussions about cost are a key component of high-quality care. Clinician/patient discussions about cost are a key component of high-quality care.

The skyrocketing cost of medical care has been front and center in the current deliberations over how to reform the country’s health care system. A new guidance statement released last week by the American Society of Clinical Oncology (ASCO) tackles one component of the issue head on, urging oncologists to discuss the potential financial costs of care with their patients. These clinician/patient discussions about cost, the guidance statement declares, are “a key component of high-quality care.”

The economics of cancer care was a focus of the recent ASCO annual meeting in Orlando, where presenters often provided frank assessments of the situation.

“We’re reaching a critical inflection point, if we’re not already past it, with respect to health care costs in this country,” said Dr. Lowell Schnipper of the Beth Israel Deaconess Medical Center, who led the ASCO task force charged with developing the guidance statement, during one of the sessions. The numbers back him up. Spending on health care in the United States was $2.2 trillion in 2007, representing approximately 16 percent of the country’s gross domestic product. Cancer, not surprisingly, is a key driver of health care costs, said Dr. Schnipper, with expenses for cancer care increasing at a clip of about 15 percent annually.

Helping Cancer Patients Find Financial Assistance

Organizations across the country, at the national, state, and local level can help patients with cancer and other serious illnesses find ways to pay for medical expenses. Many of these organizations, including CancerCare and the American Cancer Society, recently established a Web site, www.cancerfac.org, to provide a centralized, streamlined way for patients in need to find financial assistance.

ASCO has also developed a new booklet, Managing the Costs of Cancer Care, which is available on their patient Web site, and NCI maintains a fact sheet on Financial Assistance and Other Resources for People With Cancer.

The new guidance statement, published in the Journal of Clinical Oncology, is intended to help not just oncologists, Dr. Schnipper explained, but also other stakeholders—including patients, insurers, and industry members—better understand how cost can affect care choices and decisions.

Cost is an issue that can no longer be ignored, stressed ASCO task force member Dr. Deborah Schrag of Dana-Farber Cancer Institute.

“We have to accept the fact that cost is part of the conversation,” she said. In other areas of health care, such as dental care, Dr. Schrag continued, discussions about the cost of care are up front, frank, and even expected. “But when it comes to cancer, because it can be fatal, we don’t accept that cost belongs on the same table in quite the same way. Now as oncologists, we are recognizing that we have to put our toes in these cold waters. We can’t avoid it any longer. Wishing the system were different doesn’t make it so.”

Oncologists should acknowledge in discussions with patients that treatments may be very expensive and “should seek to identify any specific cost-related barriers to optimal treatment,” the guidance document recommends. To aid in these discussions, oncologists should be “armed with information that will help them assess and communicate the value of specific cancer treatments,” including trying to quantify “how much benefit might be expected from a particular therapeutic option.”

These aren’t easy conversations to have, acknowledged Dr. Nicholas Robert, who specializes in breast cancer treatment for a large oncology practice in Virginia that is part of the nationwide oncology company U.S. Oncology. “It’s different than the way we have been trained, with an emphasis on making a diagnosis and treatment.”

In the current health care environment, “Everyone will have to do their part, and physicians are responsible for a lot of expenses,” Dr. Robert continued. “We need to play a more active role not only in discussing cost with patients, but also in using resources in an evidence-based fashion and not using treatments of unproven value.”

And, he argued, such discussions make sense from a practical perspective. “One of the proper things to do is to make sure patients can afford” the treatments being prescribed, he stressed. The electronic medical records system used by U.S. Oncology aids in cost discussions, he said, because it has embedded “clinical pathways” that lay out the treatment options for a given cancer type that national guidelines indicate are the most effective. This can help oncologists develop more suitable treatment plans for their patients.

Oncologists aren’t alone in their reticence to bring up cost. “A lot of patients are uncomfortable talking about costs,” said Diane Blum, executive director of CancerCare, a New York-based nonprofit organization that provides support services for cancer patients. In some cases, she said, “patients are scared it will have an influence” on their treatment.

“We’re not saying that physicians should be experts on insurance or even have all the direct conversations [with patients],” stressed Ms. Blum, a patient representative on the ASCO task force. “But it has to be some place in the care protocol. Ideally, the physician would talk about the relative costs and benefits of treatment, but the doctor doesn’t have to be the one to help the patient sort out what a situation will allow them to choose.”

Carmen Phillips