Morganna Freeman- Keller, DO, PGY5
On a recent day in hematology clinic, I stood dutifully by my attending as he sorted through bone marrow slides. Upon opening the slide carrier he sighed and asked, “Why did they do all these unnecessary stains? It just drives up the cost, and that affects the patient.”
Although this comment may have seemed offhand, it was just as instructive to me as learning to read an aspirate. Everywhere around us, people are talking about costs in healthcare. The growing concern about soaring expenditures in oncology is hardly news: Google “rising cost of cancer care,” and you’ll find nearly 23 million search results. The hottest topics in medicine today are “cost-conscious” and “high-value” care.
Costs in oncology are rising faster than costs in many other sectors of medicine: cancer care costs increased from $72 billion in 2004 to $125 billion in 2010, and are projected to reach $173 billion by 2020.1
The increasing number of new cancer cases, the costs of emerging therapies, survivorship care, and unnecessary or ineffective testing are all important factors.
The Ballooning Costs of Cancer Care
Despite advances in cancer prevention, by 2030 the number of new US cancer cases is expected to increase by 45%—from 1.6 million to 2.3
million cases annually—driven largely by our nation’s rapidly aging population.2,3
Although targeted drugs and immunotherapies show great promise, they are extremely expensive. Eleven of the 12 cancer drugs approved by the FDA in 2012 cost more than $100,000 per year.4
The use of novel cancer therapies in combination with other drugs is costly, even for those who are insured, and high costsharing has already demonstrated negative impacts on medication adherence and health outcomes.5
The costs of cancer survivorship also play an emerging role. As care improves, so does survivorship, and currently there are 14.5 million survivors in the United States.6
However, it is important to recognize that in addition to the possibility that cancer may recur, survivors are at risk for treatmentrelated comorbidities such as diabetes and cardiovascular disease.
For this reason, multiple healthcare professionals may play a role in a patient’s care, which can affect overall costs of care. One study estimated the economic burden of survivorship to be more than $16,000 annually per patient.7
Unnecessary testing contributes to excessive costs as well, and may be harmful to a patient. A recent study analyzing outcomes in lung cancer patients demonstrated that physicians who failed to follow established clinical guidelines when providing care to their patients used more invasive testing and had higher rates of complications.8
Discussing “Financial Toxicity”: Is It Equivalent to “Do No Harm?”
A 2009 guidance statement by the American Society of Clinical Oncology (ASCO) about the overall cost of cancer care advised that physicians “must understand the unique needs of each patient when making treatment decisions, including consideration of out-of-pocket costs.”9
This sentiment was echoed in a 2013 Institute of Medicine report which recommended that oncologists “provide patients and their families with understandable information about cancer prognosis, treatment benefits and harms, palliative care, psychosocial support, and costs.”1
Providing patients and their family members with information about costs, perhaps not coincidentally, falls at the end of this long list. Yet, medical debt remains a critical issue for cancer patients and their families.
A recent Kaiser Family Foundation study noted that 1 in 3 Americans reported difficulty in paying medical bills. Although the risk of medical debt is greater for the uninsured, many insured patients also experience difficulty paying their bills.10
Another study demonstrated that cancer patients were 2.65 times more likely to file for bankruptcy than those without cancer.11
Medical debt can lead to credit card debt, bankruptcy, barriers to receiving necessary healthcare, and difficulties in paying for basic necessities such as meals and housing. Additionally, cancer can affect a patient’s ability to work, or can prompt a working family member to quit or reduce their hours worked in order to become a caregiver.
Many patients and family members, already struggling with the emotional burden of cancer, don’t know where to seek financial help. Although 75% of pre-retirees believe that their top fear in retirement is uncontrollable healthcare costs,12
only 21% of patients surveyed in a recent analysis actually chose to discuss their fears with a professional.13