Increased funding for research, early detection and prevention are seen as keys to stem the rising costs of treating cancer
BY HIMANEE GUPTA-CARLSON
On the eve of the new millennium, the Pew Research Center surveyed Americans’ predictions for the 21st century. One question that Pew asked its respondents dealt with the future of cancer, and the 1,500 adults surveyed offered an upbeat prognosis.
Eighty percent said they expected a cure for cancer would probably be found within the next 50 years. Twenty percent believed a cure would definitely be found.
Advances made in cancer research and treatments suggest the optimism that the survey respondents expressed was more than a dream. More people who learn that they have cancer are receiving treatment and are living to speak about their recovery.
Death rates for the four most common cancers—prostate, breast, lung and colorectal—have declined since the mid-1990s, as the National Cancer Institute details in its 2007 update, Cancer Trends Progress Report.
The NCI also notes that cancer incidence rates—as a percentage of the overall population—have been dropping steadily since the early 1990s. And, new biotechnology drugs have the ability to perform miracles in people whose illnesses would have been considered untreatable a decade ago. All of these figures represent good news for the more than 1 million Americans who are diagnosed each year with cancer.
“We are in an era of cancer research and treatment that shows a rapidly ascending trajectory for new treatments to be effective,” said Dr. Lowell Schnipper, chief of the Division of Hematology/Oncology at Beth Israel Deaconess Medical Center in Boston.
But, as Schnipper and a growing number of cancer care experts are beginning to point out, there is a grim side effect to this success: sticker shock.
As the nation ages, and with people living longer, the number of cancer cases is increasing significantly—and so is the cost of treating them. Without a clear consensus on how to deal with the problem, some experts are looking to science to provide some answers.
Escalating bills
Schnipper is co-chair of a task force organized by the American Society of Clinical Oncology that is preparing guidelines to help oncologists discuss the cost of cancer care with their patients.
That work comes as the costs of treating cancer continue to rise. The NCI reports that cancer treatments accounted for $72.1 billion in 2004, about 5 percent of the spending for all medical treatment.
While the percentage might seem small given the gravity of the disease, the overall costs of treating cancer increased by 75 percent between 1995 and 2004. The NCI notes that more people are likely to be treated for cancer as the population ages, and that adopting the newer, more expensive treatments as standard forms of care will continue to increase the spending.
Other studies predict the number of annual diagnoses of cancer in the United States may double by 2050, and that costs for caring for persons over age 65 who are living with cancer may reach $21.1 billion over the next five years.
These sobering statistics raise a sensitive question: What happens if the cost of treating cancer grows so large that society cannot afford the burden of care?
“The costs of treatment often ring up a bill of tens of thousands of dollars, perhaps even $100,000 or more,” Schnipper said. “In addition, treatment often occurs in combination with a variety of drugs. The cost spirals as a result of research and development, manufacturing, and, of course, the marketing of drugs. When you start adding all of these factors up, it can get very expensive.”
The society of oncology is taking a proactive approach to the question of cost through the preparation of guidelines. According to Schnipper, questions that the guidelines will address are: Is it ethical for physicians to discuss questions of cost with patients and, if so, how? How might the question of cost be brought into the patient-physician dialogue without embarrassment? What research questions might be formed on how to value various therapies? And how, in a policy sense, might the cost of a new cancer treatment be factored into decisions over whether to approve it for general use?
“We felt we needed to assess this problem of cost on a broad range of fronts and educate our membership on how to communicate this information to patients,” Schnipper said. Teasing apart the economic impact of cancer care to patients, Schnipper adds, allows them the choice of weighing the option of treatment against the reality of taking out a second mortgage or not paying for a child’s education.
Is it ethical for society, as a whole, to pay the price for treatments that benefit only a few?
“If every treatment were saving a life, one might say that the cost to society is worth it,” Schnipper says. “But the reality is that treatments can be developed—often with the highest of aspirations—that very often fall short of that goal.”
Dr. Scott Ramsey, a cancer researcher, physician and health economist at Fred Hutchinson Cancer Research Center, said society faces tough choices as cancer-care costs continue to escalate.
“The treatment for colon cancer once cost $30,000. Today, depending on the gravity of the disease, it can cost $150,000 or more,” he said. “The good news is that people are living longer. The bad news is that we have more people with cancer and the cost bubble is growing.”
One of the problems behind escalating costs is that “cancer treatments are not being applied uniformly. Cancer care is all over the map. People are being undertreated or overtreated,” Ramsey said.
Another major problem is drug treatments, which carry a high price. Some of these drugs can easily cost $100,000, but may extend life only by a few months. “Is this a good way to spend our health dollars?” Ramsey said. “Are we treating the anxiety or the hope of the patient?”
In some countries, governments that bear the burden of health care are asking these tough questions and making formal assessments as they seek to establish uniform standards of care, he said.
Cancer’s social cost
To map the costs of cancer to society, it helps to look at what an individual patient might face. Damon Spark, a former carpenter, learned in February 2007 that the back and leg pains he had been experiencing were the result of a late-stage lymphoma cancer. He was rushed into treatment and over the next several months, underwent surgery, chemotherapy, radiation therapy, and a series of other tests. He was in and out of hospitals for eight months, and his bills totaled nearly $500,000.
Spark, 36, was self-employed and healthy. Prior to his diagnosis, he hadn’t worried about health insurance. Fortunately, his mother had taken out an insurance policy for him, and although it came with a high deductible, it did cover most of his costs. With help from financial counselors through the American Cancer Society, he also received assistance from Medicaid and Social Security.
“I’m grateful to have had the opportunity to recover from this,” Spark said, “especially when I see what a drain these costs were for my family and for all of these other sources.”
Patients who have insurance through employers often find that the cost of premiums, deductibles and co-payments drives up their own share of their medical bill. In addition, many insurers refuse to cover certain drugs or place caps on the amount they will cover. Private insurers generally require patients to start with a cheaper drug or make a bigger co-payment. In addition, approximately 45 million Americans are uninsured. Within this reality, who pays the cancer bill?
A cancer society publication, Advanced Illness: Financial Guidance for Cancer Survivors and Their Families, offers some clues. When existing insurance cannot cover the costs, patients are urged to consider buying additional coverage, usually for a higher cost. In some cases, cancer patients are deemed uninsurable or are among the growing ranks of the uninsured. In these cases, taxpayers pick up the bill. Some states offer medical coverage, and the federal government provides money for cancer treatment through its Hill-Burton program to some hospitals or other medical facilities.
As Dr. Lee Newcomer, an oncologist and senior vice president of oncology at UnitedHealthcare in Minnetonka, Minn., a major health insurer, puts it, “If the question of extending your life by a few months or possibly a year comes down to having to trade in your child’s education or the possibility of your family’s health insurance, what do you do?”
Newcomer looks at the cost of cancer in terms of a pie chart. First, one must understand what share of the medical spending pie cancer occupies. Among the medical claims that UnitedHealthcare processes, Newcomer estimates that share to be 11 percent. Within cancer’s piece of the pie, Newcomer attributes about 20 percent of the cost to chemotherapy treatments and drug prescriptions. An additional 25 percent is expended on hospitalization costs. The remainder goes toward radiation, post-recovery and other treatments.
“So, if you look at the pie,” Newcomer said, “you can see that the drugs that patients are treated with and the time that they spend in the hospital receiving that treatment accounts for more than half of the price. Those two areas also are the two areas that are rising at the most rapid rate.”
Old culture: ‘Let’s try anything’
New, powerful biotechnology drugs have come under scrutiny from cancer care experts concerned about their cost and effectiveness.
So why administer such treatments if the effectiveness is limited and the price tag is high? Many experts attribute this to a tendency within the world of cancer care to ‘try anything’ to save a life.
Schnipper offers a hypothetical example of a patient diagnosed with a late-stage cancer: “You might feel desperate. You want to fight the cancer. You might read about a promising new treatment, and even if it offers only a modest ability to cure, you might push your doctor to try it. Doctors, of course, want to help their patients in any way that they possibly can.”
That culture of ‘let’s try anything’ is, in many ways, an aspect of the hope Americans expressed in the Pew survey when they predicted that a cure for cancer will be found. If a willingness to try anything has saved one life, it might save your own. The problem, however, is that federal safety regulators do not look at what a drug costs. They only examine whether or not the drug has worked.
“Ultimately, the use of expensive drugs will drive premiums up,” Newcomer said. “As premiums go up, people start to drop their insurance.” And, Newcomer added, as the number of uninsured individuals goes up, the social cost of cancer escalates.
Newcomer advocates the use of clinical trials to determine the effectiveness of a drug, and the elimination of treatments defined as nonstandard. “That old culture of ‘let’s try anything’ can be redirected to ‘let’s look at what works and make sure we’re using the right therapies on the right people.’”
Stopping cancer in its tracks
The society of oncology plans to release its guidelines on discussing cost issues with cancer patients later this year. In the meantime, growing evidence indicates that steps to prevent cancer as well as detect the disease early may be key long-term steps in curbing the costs.
Experts believe that more than two-thirds of all cancer cases could be prevented if individuals stop smoking, exercise regularly and make other healthy lifestyle choices such as eating a diet rich in fruits and vegetables.
The NCI’s Progress Report notes that public awareness of what people can do to prevent cancer from developing in their own bodies has helped lower the number of smokers in the United States and encouraged no-smoking policies in public places throughout the country. Experts link these practices to a lowered incidence of lung cancer.
Similarly, an increased emphasis on making cancer-detection procedures such as colonoscopies and mammograms a regular part of individual annual physical health care regimens are strong possible contributors to the lowered incidence of cancer. Ramsey, who also oversees the Cancer Prevention Clinic at the Seattle Cancer Care Alliance, said the benefits of early detection and prevention have the potential to make a big dent in cancer-care costs.
“As the cost of treating cancer goes up, so does the value of early detection,” he said. “But cancer screening and prevention, even though they’re among the most cost-effective things we can do in the health-care system, are far from being routine.”
Colon cancer, for example, is the second-leading cause of cancer deaths in the United States but is highly treatable when caught early. But Ramsey points out that many insurers won’t cover colorectal screening. Washington is one of only 25 states that has passed colorectal-screening legislation.
“We have to be willing to invest in cancer screening, and we have to lower the financial barriers that are keeping people from seeking preventive care,” he said.
Coupled with screening is a more powerful weapon against cancer: continued research.
“There’s great hope for the work that’s being accomplished in cancer research, and for the potential to lower costs and improve outcomes,” Ramsey said.
But the question of how well humans act upon what they know is something that might be impossible to gauge. Before he learned he had cancer, Spark smoked a pack of cigarettes a day, indulged in fast food, and worked at sites where he was exposed constantly to hazardous chemicals.
But now he has quit smoking and eats fresh vegetables and salads daily.
“The cost and the pain that I went through has made me look at the value of life over the long term,” he said.
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