"The possible harm of early adoption is negligible, and the cost of not intervening is close to $2 billion per year. I strongly feel IORT should be adopted now. I don’t think the results are going to change. We’ve already adopted it at our center, and a registry trial is being organized to help people adopt it nationally," said Dr. Esserman.
A major obstacle here is Medicare’s decision to make IORT part of a bundled-care program, which means that physicians who perform radiation therapy intraoperatively won’t get paid more for it. "This will provide an enormous disincentive to the use of IORT. The big losers here are the patients," she said.
Another opportunity to save money would be to follow the U.S. Preventive Services Task Force guidelines on mammography screening for breast cancer, rather than routinely conducting annual mammography, as many physicians still advocate, Dr. Esserman continued.
"We could save $5 billion per year simply by following those guidelines. And there are now many papers demonstrating that approach certainly is very cost effective. You don’t find any significant increase in advanced cancers with annual screening," she said.
Five More Proposals to Slow Costs
Dr. Smith proposed the following five changes in oncologists’ behavior aimed at slowing the rise in cancer care costs:
• Target surveillance testing with serum tumor markers and imaging in accord with NCCN guidelines. Recommendations to cut back on surveillance testing ought to be incorporated into the American Society of Clinical Oncology’s Quality Oncology Practice Initiative (QOPI), a program of proven effectiveness in changing medical oncologists’ behavior.
• Switch to palliative care in patients with disease progression despite three consecutive chemotherapy regimens. The US Oncology Network’s pathway for metastatic non–small cell lung cancer, which takes this approach, has been shown to reduce treatment costs by 35% with exactly the same survival as in patients treated off pathway – and with better quality of life stemming from a doubled length of stay in hospice care (J. Oncol. Pract. 2010;6:12-18). The same research group reported that a similarly structured pathway for metastatic colon cancer led to a reduction in treatment costs by one-third, along with a significant 6.8-month improvement in survival compared with off-pathway treatment (Am. J. Manag. Care 2011;May [suppl. 5 Developing]: SP45-52).
• Limit chemotherapy for most patients with advanced metastatic solid tumors to patients with good performance status. This would markedly decrease the use of chemotherapy at the end of life.
• Substitute a reduction in chemotherapy dose for the current routine use of colony-stimulating factors in patients with metastatic solid cancers. "We are 3% of the world’s population and we use 75% of the world’s colony-stimulating factors. And 90% of that use isn’t supported by ASCO guidelines," the oncologist asserted. "I think that’s going to be a big target going forward. We simply can’t afford $3,500 per injection for a drug that helps with supportive care but doesn’t improve survival."
• Sequential monotherapies rather than combination chemotherapies as second- and third-line treatment for metastatic cancer. The available data suggest patients will live just as long, but with fewer toxic effects – and at lower cost.
Personalized Medicine and Palliative Care
Dr. Hassett cautioned that although conventional wisdom holds that the emerging field of "personalized medicine" will favorably impact health care costs by providing more selective therapy and improved clinical outcomes, that’s by no means a slam dunk.
"I’m just not sure. I think there’s a chance that personalized medicine could actually increase costs by introducing more expensive tests, new and more expensive drugs, and more complexity into the system," he said.
One thing he is sure of, however, is that any successful effort to reduce the rate of growth in cancer care spending will necessarily have to address the hot-button issue of end-of-life care. One-tenth of all Medicare dollars are spent on care during the final 28 days of life.
Dr. Smith concurred, adding that ASCO has a soon-to-be-published Provisional Clinical Opinion declaring that all oncologists should integrate palliative care into their usual cancer care programs.
"That should be the norm. We have to look at how we spend that money for end-of-life [care] because if we don’t fix that part, we won’t have money for adjuvant therapy and neoadjuvant therapy and funding for major research," he warned.
None of the experts cited in this article declared having any financial conflicts.