oncology

1. BALANCE ETWEEN QUALITY
AND COST IN CANCER
MANAGEMENT
DR: SUMMAR MOHAMED
ELMORSHIDY
ASSISTANT LECTURER OF CLINICAL
ONCOLOGY
CLINICAL ONCOLOGY DEPARTMENT
ASSIUT UNIVERSITY HOSPITALS

2. The Cost of Cancer Care
Balancing Our Duties to
Patients Versus Society:
Are They Mutually Exclusive?

3. Introduction
 It is a disturbing fact that the costs of health care are spiralling upwards and that
the best example of this troubling trend is the domain of oncology treatment and
research.
 By 2020, it is projected that cancer care will cost more than $150 billion
annually in the United States. Although this represents only a relatively small
fraction of total health care cost, cancer care is escalating more rapidly than most
other specialties.
 Many factors contribute to this unhappy situation, including the
 aging of the population,
 persistence of risk-taking by the community at large (smoking, excessive sun
exposure, and lack of attention to industrial pollution)

4. Introduction
increasingly expensive research, diagnostic tests, surgical approaches,
radiotherapy techniques,
 and novel systemic therapies as well as
some unrealistic expectations of patients, families, and the community
at large .

5. Introduction
 The prospect of cancer treatment is difficult to
deal with for most patients when one considers
the nature of the treatment being offered and
its potential consequences.
 In addition,
 asymmetry of medical information,
 dislocation of patients and their families for
treatment far from their homes
 mean patients lose control over their lives,
compounding their anxiety over a cancer
diagnosis and the treatment that follows.

6. Introduction
 At its simplest, the value proposition in health
care has been defined by Porter and Teisberg
with the following equation:
Value=Outcomes/Cost
 This equation makes sense and is routinely used in
planning the strategy of cancer care for health
care systems as it help to consider what is
contributing to poor value in cancer care and
allows resolution of those elements that are
accessible.

7. In summary

8. How much is spent on
oncology drugs?

9. Spending in Leading Therapy Areas in
the United States, 2011

10. Oncology spending by area

11. Price of FDA-approved Oncology
Drugs

13. How does all this affect
the political system and
healthcare service?

15. (ESMO 2020 vision)
Cancer patients and their needs are at the centre
of all that we do: our profession is driven by our
determination, individually and collectively, to
secure the best possible outcomes for people
with cancer across Europe and around the world.

16. We have to answer these
questions in order to
improve our practice

17.  As oncologists, we find ourselves asking: Is our
duty to our individual patients, to society, or to
both?
 How will we do our part to contain health
care costs while honoring therapeutic contracts
and professional obligations to do the best for
each patient?
 How will the increasing pressure to control
expenditures affect the way that oncologists
communicate with patients about tests and
treatments?

18. Is Our Duty to the Patient or
to Society?
 An ethical conflict arises when one feels that the interests of the
patient are at odds with the interests of society!!!
 Oncologists are bound by duty to patients as stated in the Hippocratic
Oath: “I will prescribe regimens for the good of my patients
according to my ability and my judgment and never do harm to
anyone.”
 Conflict arises when care delivered to an individual patient is part of a
pattern that risks harm to society. In this case, the societal “harm”—or
more accurately, burden—is in the form of skyrocketing costs of care.

19. Examples
 Oncologists are often asked by their patients with early-stage breast
cancer for periodic scans and tumor markers in hopes of detecting
metastatic disease before symptoms arise.
 Randomized studies show that routine surveillance for metastatic disease
does not prolong survival or improve health-related quality of life, may
lead to unnecessary or invasive testing, and contributes significantly to
the cost of follow-up care.
 As a rule, physicians should not feel compelled(forced or pressured) to
participate in expensive care that is not rooted in medical evidence.

20. Examples
 However, in some situations, the decision making becomes more complex;
that is, novel therapies may provide a marginal benefit, but at a high
cost. For example, in the case of HER2-positive breast cancer, data in
the neoadjuvant and metastatic settings show that additional HER2-
based therapies given with trastuzumab, such as lapatinib and
pertuzumab, may further improve outcomes .
 Most recently, trastuzumab-DM1 was approved for the treatment of
metastatic HER2-positive breast cancer, and clinical trials in the
adjuvant setting are planned.

21.  If additional benefit of these drugs is confirmed in large
adjuvant randomized trials, one can imagine a scenario in which
oncologists are forced to decide on further improving outcomes
versus doubling or tripling the cost of therapy. As an example,
the cost of trastuzumab-DM1 is $9,800 per month
of treatment, for an additional 5.8 months of life in
patients with metastatic disease.

22. How will we do our Part
 providing a Symmetrical System of Cancer
Care
 CHOOSING WISELY
 Shared Decision-Making: The Balance
Between Evidence-Based Medicine and
Patient-Centered Care?

23. Criteria for a Symmetrical
System of Cancer Care

24. CHOOSING WISELY
 One of the most important aspects to reduction of
unnecessary expenditure in oncology is the
consideration of what is gained by the use of the
available management approaches.
 The Institute of Medicine has encouraged physicians
to carefully consider the benefits and drawbacks
associated, in particular, with expensive management
options in the so-called “Choosing Wisely” campaign.

26. Shared Decision-Making: The Balance
Between Evidence-Based Medicine and
Patient-Centered Care?
 It is thought that two parallel philosophies predominate in
modern medicine: evidence-based medicine (EBM) and patient-
centered care (PCC)
 EBM is defined as “the conscientious, explicit, and judicious
use of current best evidence in making decisions about the care
of individual patients.
 PCC focuses on the patient's preferences for treatment and
participation in decision making.

27.  EBM attempts to standardize care and create clinical algorithms,
whereas PCC aims to promote autonomy and the inclusion of the individual
patient in medical decision making. Both disciplines strive to improve quality
of care and, ultimately, health outcomes.
 A growing body of literature indicates that patients who participate actively
in the decision-making process are more satisfied with the quality of care
 However, the evidence has not uniformly incorporated into routine oncologic
care, and a minority of patients participate in a truly shared approach to
decisions

28. SUMMARY and
Recommendations
 The exponential increase in costs of health care is unnecessary and
reflects many avoidable factors at a community level, including poor
health practices, unrealistic expectations, corporate profiteering
(unethical projects), and a poor medical decision process (which
often contravenes level 1 to 2 evidence).
 Physicians must increasingly consider true value (outcome/cost ratio)
when creating management plans and include these considerations in
transparent and realistic conversations with patients. Attention to
these issues will dramatically reduce the increasing costs of cancer
care in our community while improving the quality and value of care.

29. Recommendations
 TRAINING THE NEXT GENERATION OF PHYSICIANS TO
INCORPORATE THE VALUE PROPOSITION.
 Training oncology residents to provide high-value care is key
to transforming the practice of oncology .
 Expressed simply, residents who do not train in high-value
care settings are less likely to become high-value physicians.
Residency faculty must be skilled in the organization and
delivery of high-value care and in how to teach those skills.

30. Refrences
 D Raghavan, MW Legnini - American Society of Clinical Oncology …, 2016 -
ncbi.nlm.nih.gov
 Porter ME, Teisberg EO. How physicians can change the future of health care.
JAMA. 2007;297:1103-1111.
 Schnipper L, Smith TJ, Raghavan D, et al. American Society of Clinical Oncology
identifies five key opportunities to improve care and reduce costs: the top five
list for oncology: ASCO’s top five list. J Clin Oncol. 2012;30:1715-1724.
PubMed | CrossRef
 Cherny NI, Sullivan R, Dafni U, et al. A standardised, generic, validated
approach to stratify the magnitude of clinical benefit that can be anticipated
from anti-cancer therapies: the European Society for Medical Oncology Magnitude
of Clinical Benefit Scale (ESMO-MCBS). Ann Oncol. 2015;26:1547-1573.
 Keirns CC, Goold SD. Patient-centered care and preference-sensitive decision
making. JAMA. 2009;302:1805–1806. [PubMed]
 Baselga J, Bradbury I, Eidtmann H, et al. Lapatinib with trastuzumab for HER2-
positive early breast cancer (NeoALTTO): A randomised, open-label, multicentre,
phase 3 trial. Lancet. 2012;379:633–640. [PubMed]
 The GIVIO Investigators. Impact of follow-up testing on survival and health-
related quality of life in breast cancer patients. A multicenter randomized
controlled trial. JAMA. 1994;271:1587–1592. [PubMed]