If the Choices Are All the Same, Why Not Prefer the Less-Expensive Option?

Cancer treatment guidelines contain many things: exhaustive references, highly detailed treatment algorithms, careful delineation of treatment doses and schedules, layered stacks of evidence ratings, and footnotes with additional nuggets of clarification or explication. But you can search most guidelines in vain to discover the most basic of all consumer information—the price. That glaring absence needs to be rectified if we ever hope to make rational choices in providing effective and affordable health care.

Some have argued that the true costs of oncology treatment are difficult to assess. Consider, for instance, administration of chemotherapy for metastatic breast cancer. One would have to know the price of the chemotherapeutic agent; cost of shipping, storing, and preparing the chemotherapy and supportive care drugs; costs of laboratory tests necessary to safely administer the drug; anticipated costs of adverse effects; and price of human labor from pharmacists, nurses, clinic assistants, and physicians to evaluate and treat the patient. Of course, estimating and calculating all of this is really quite doable. The average neighborhood restaurant determines how to price a meal made with many hands and using many ingredients, and an aircraft manufacturer knows the costs of assembling a plane created by thousands of people using millions of parts.

A fear of cost determinations is that they readily lend themselves to cost comparisons. And the further fear—not applicable in restaurants or manufacturing— is that cost comparisons imply serious contemplation of trade-offs between cost and efficacy for patients with cancer.

However, there are situations in which cost comparisons can be easily made without any concern about trade-offs. Those situations are frequently found in guidelines. Consider treatment of first-line metastatic breast cancer, colorectal cancer, and lung cancer—all situations commonly encountered by community oncologists. The current NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) list more than 10 “preferred” chemotherapy options for advanced breast cancer. First-line treatment for colorectal and lung cancer shows 3 or 4 options each. Noting these options as equally preferred implies that they are comparably effective and safe, according to the best available evidence and scholarly review. Under these circumstances, wouldn’t it make sense that a simple cost comparison would identify the less-expensive choices? Then, safety and efficacy being equal, wouldn’t those choices be the ones truly “preferred?”

Let’s focus on one clear-cut instance of using price to identify a preferred regimen. Recently, ASCO updated its guideline for the use of bone-modifying agents in metastatic breast cancer.1 The guideline recommended using 1 of 3 treatments: denosumab, zoledronic acid, or pamidronate. The NCCN Guidelines for Breast Cancer2 also recommend the exact same 3 drugs (to view the most recent version of these guidelines, visit the NCCN Web site at NCCN.org). These agents are each administered in the outpatient clinic on the same monthly schedule. They each require the same laboratory monitoring. They each have similar side effect profiles. They are each considered equally effective based on randomized trials of one versus another. Two separate expert panels have endorsed using any one of these agents, finding in their best professional opinions that the evidence suggests equal utility and tolerability. Thus, there is no question of compromising clinical care when considering these choices.

As pointed out in both the ASCO and NCCN guidelines, these drugs do differ markedly in convenience of administration. Denosumab is a subcutaneous injection. Zoledronic acid is a 15-minute intravenous infusion. Pamidronate is a 2-hour intravenous infusion. An even more marked difference, and one not pointed out in either set of guidelines, is in price. Denosumab costs approximately $1650 per treatment; zoledronic acid, $887; and pamidronate, $90.3

If one equally effective drug costs twice the price of another, why is the cheaper drug not the preferred option? If convenience or chair-time are critical factors in treatment decisions by clinicians and patients, should they not pay something for that convenience?

Here then is a clear example of where the oncology community could better inform treatment decisions by factoring in price, without in any way asking patients to compromise their care or jeopardize their health. It is also a situation in which expert panels could identify a preferred option based on economic considerations. Those who want to factor in the value of a treatment based on convenience or infusion-time also have the data at hand to do so. Miraculously, this example defines a formula that links time and money.

It is time for serious dialogue on cost-effective care, and a good place to start would be a situation in which you can have the best of both worlds.

The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of NCCN.

References

  • 1

    Van PoznakCHTeminSYeeGC. American Society of Clinical Oncology executive summary of the clinical practice guideline update on the role of bone-modifying agents in metastatic breast cancer. J Clin Oncol2011;29:12211227.

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  • 2

    CarlsonRWAllredDCAndersonBO. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer version 1.2012. Available at http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed March 15 2012.

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  • 3

    CarterJASnedecorSJKauraSBottemanM. Cost-effectiveness of zoledronic acid (ZOL) versus denosumab (Dmab) in prevention of skeletal-related events (SREs) in metastatic breast cancer (mBC) [abstract]. J Clin Oncol2011;29(Suppl 27):Abstract 294.

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Harold J. Burstein, MD, PhD, editor-in-chief of JNCCN, is an Associate Professor of Medicine at Harvard Medical School and a medical oncologist at Dana-Farber Cancer Institute and Brigham & Women’s Hospital. He is a clinician and clinical investigator specializing in breast cancer.Dr. Burstein attended Harvard College and earned his MD at Harvard Medical School, where he also earned a PhD in immunology. He trained in internal medicine at Massachusetts General Hospital and was a fellow in medical oncology at Dana-Farber before joining the staff.Dr. Burstein’s clinical research interests include novel treatments for early- and advanced-stage breast cancer and studies of quality of life and health behavior among women with breast cancer. He has written widely on breast cancer in both traditional medical journals and on the web, including New England Journal of Medicine and Journal of Clinical Oncology. International committees focusing on cancer treatments that he has or continues to participate in include the NCCN Clinical Practice Guidelines Breast Cancer Panel, St. Gallen Breast Cancer Panel, CALGB Breast Cancer Committee, ASCO Health Services Research and Clinical Research Committees, the National Quality Forum Breast Cancer Technical Panel, and other ASCO expert panels.
  • 1

    Van PoznakCHTeminSYeeGC. American Society of Clinical Oncology executive summary of the clinical practice guideline update on the role of bone-modifying agents in metastatic breast cancer. J Clin Oncol2011;29:12211227.

    • Search Google Scholar
    • Export Citation
  • 2

    CarlsonRWAllredDCAndersonBO. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer version 1.2012. Available at http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed March 15 2012.

    • Search Google Scholar
    • Export Citation
  • 3

    CarterJASnedecorSJKauraSBottemanM. Cost-effectiveness of zoledronic acid (ZOL) versus denosumab (Dmab) in prevention of skeletal-related events (SREs) in metastatic breast cancer (mBC) [abstract]. J Clin Oncol2011;29(Suppl 27):Abstract 294.

    • Search Google Scholar
    • Export Citation
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