Washington, DC—Treatments and technologies for cancer care are becoming increasingly expensive, fueling a need to define and improve value. As a result, the American Society of Clinical Oncology (ASCO) is refining its value framework that supports informed shared decision-making between doctors and patients and considers the clinical benefit, cost, and toxicity of cancer treatments. The goal is to have a tool that can customize information for each patient.
Lives are being saved through improved cancer care in a clearly demonstrable but perhaps underappreciated way, said Clifford Hudis, MD, Chief Executive Officer of ASCO, at the Sixth Annual Conference of the Association for Value-Based Cancer Care. “We need to get that message out if anybody is questioning the utility and value of cancer therapy,” he said, noting that over the past 2 decades more than 1.5 million cancer deaths have been averted as a result of improvements in cancer care.
Trends in Cancer Care
Anticipated trends in cancer care include the collection and use of big data through electronic medical records, more reliance on technology, and an increased cost of drug development. “Thrown into this mix is the unpredictable impact of ongoing healthcare reform,” Dr Hudis added.
Risk factors that may have an impact on cancer care include obesity and increasing age.
An explosion in the rate of obesity, which Dr Hudis said is projected to worsen by 2030, has broad health implications. Obesity has been directly linked to a rising incidence of the most common solid tumors and hematologic cancers.
“Breast cancer, especially estrogen receptor–positive postmenopausal; colon cancer; and high grade prostate cancer all are associated with obesity,” Dr Hudis said.
Obesity coupled with an aging population are 2 tsunami waves that will increase the burden of cancer in the years ahead, he added.
Cost Drivers of Cancer Care
With the acceptance of new types of evidence and novel approaches to streamlining drug approvals, the FDA has been increasingly liberal in its approval of cancer drugs, suggested Dr Hudis. Drugs are a fast-growing component of the cost of cancer care, with newer agents costing an average of $10,000 monthly, which is an increase from $5000 monthly a decade ago.
The technologies emerging for cancer treatments are expensive, even if they are not evidence-based, and the value they provide is not always clear.
“There are some diseases right now where sequencing the genome leads you to approved therapies that deliver improved outcomes,” Dr Hudis said. “That’s a fact, but there are far more situations where that testing is being done and the utility is yet to be demonstrated. There’s a tension between our enthusiasm for that technology and the evidence that it’s actually useful.”
Other cost drivers include a lack of well-coordinated complex cancer care and a payment system that is not always aligned with the goals of the healthcare system.
An increase in patient out-of-pocket costs reflects the growth in health spending in the United States. This burden is greater for patients with cancer than for those with other chronic diseases, Dr Hudis noted. The increasing out-of-pocket costs have adverse effects on patient care, often in the form of suboptimal adherence to prescription medicines. Although patients would like to discuss the cost of cancer care with their provider, they are not sure how to broach the topic, he said.
In 2009, ASCO produced a toolkit for patients and families on managing the cost of cancer care. Its “Choosing Wisely” campaign, in conjunction with the American Board of Internal Medicine, assembles lists of treatments, tests, and procedures whose common use and clinical value are not supported by evidence. In 2015, ASCO began to develop a patient-centered oncology payment model.
ASCO Value Framework
Dr Hudis described the ASCO value framework, a conceptual tool for helping physicians and patients objectively assess the costs and benefits of a cancer treatment in a transparent way. The framework was designed with the realization that cost is having a growing impact on patients.
“This was meant to be a work in evolution, designed to encourage patients and doctors to have open discussions about costs,” he said. “It was meant to incorporate clinical benefit defined however we want, toxicity, and cost, and we wanted it to be customizable for each individual patient while supporting the notion of the patient–physician relationship.”
The output of the ASCO value framework is net health benefit, taking into account clinical benefit, toxicity, and cost. Points are assigned to each, with bonus points awarded for innovation, to obtain a score that approximates the benefit that patients may receive from a new cancer drug relative to the standard of care.
The Promise of Big Data
Of the estimated 1.7 million people who were newly diagnosed with cancer in the United States in 2016, 97% of their data are locked away in unconnected files and servers, because only 3% of patients with cancer are enrolled in clinical trials.
“That means that we don’t really have the opportunity to learn very much from almost everything that we do in the healthcare system,” Dr Hudis said. “When you get right down to it, when we’re palliating so many millions of patients, when we have 500,000 plus deaths a year from cancer just in the United States, we clearly need to do better.”
The Targeted Agent and Profiling Utilization Registry (TAPUR) study was designed to learn from the real-world practice of prescribing targeted therapies to patients with advanced care who receive a targeted drug based on a genomic variant that their tumor harbors.
The TAPUR study was launched in March 2016 at 35 sites; it now has 37 sites, with significant site expansion planned soon. As TAPUR succeeds, physicians will be receiving guidance in the interpretation of genomic test results and treatment options, as well as access to drugs and clinical data from the off-label use of therapies. Payers will receive data on test and drug use and outcomes to inform future decisions. The pharmaceutical industry will receive data on drug use and outcomes to inform research and development plans.