Study finds broad support for rationing of some types of cancer care

The majority of cancer doctors, patients, and members of the general public support cutting health care costs by refusing to pay for drugs that don't improve survival or quality of life, according to results of a new study that will be presented by researchers from the Perelman School of Medicine at the University of Pennsylvania during the annual meeting of the American Society of Clinical Oncology in Chicago in early June (Abstract #6518).

The Penn Medicine team surveyed 326 adult receiving treatment at Penn's Abramson Cancer Center, a random sample of 891 adults in the general public, and 250 across the United States during 2012 to probe their opinions about tactics for controlling costs associated with .

"We found that the majority of respondents considered Medicare spending a big or moderate problem, and many suggested that Medicare could spend less without causing harm," said the study's lead author, Keerthi Gogineni, MD, MSHP, an instructor in the division of Hematology-Oncology in Penn's Abramson Cancer Center. "We know that cancer and their doctors face decisions every day that stand to raise without conferring much benefit to patients, and our survey has identified some common themes in how these groups of stakeholders might propose to lower costs of care while still protecting patients."

More than 90 percent of all three groups surveyed attributed rising costs to drug companies charging too much, and more than 80 percent of each group cited insurance company profits as a driver of rising costs. Many also thought hospitals and doctors conducted unnecessary tests and provided unnecessary treatments (69 percent of patients, 81 percent of the general public, and 70 percent of doctors).

The research team, which includes senior author Ezekiel J. Emanuel, MD, PhD, chairman of the department of and Health Policy, presented a variety of potential cost-lowering options to each group and asked whether they supported the idea. Cancer patients, members of the general public, and oncologists tended to be about as likely to say patients who can afford to pay more for care should be asked to pay more (56, 58, and 52 percent, respectively). And large numbers favored not paying for more expensive drugs when cheaper alternatives are equally as effective (78 percent of patients, 86 percent of the general public, and 90 percent of physicians). The majority also supported refusing to cover drugs that do not improve survival or quality of life, though physicians were more apt to refuse payment under those circumstances (79 percent compared to 52 percent of patients and 57 percent of the general public).

Even drugs that confer only incremental gains in survival, however, were found to be worth covering in the eyes of all groups surveyed: Just 12 percent of physicians were willing to refuse payment for a drug that extends life by four months, compared to 20 percent of patients and 28 percent of the general public.

Greater differences of opinion were observed around coverage for drugs offering benefits other than survival gains. When queried about a drug that doesn't extend life but reduces pain, for instance, only 5 percent of patients and 10 percent of the general public voiced support for refusing to cover the medication, compared to 32 percent of physicians. On coverage for a drug that doesn't extend life but adds convenience, 27 and 32 percent of patients and the general public, respectively, said those costs should not be covered, compared to 59 percent of physicians.

"These results suggest that patients and the lay public prioritize quality of life, while oncologists appear focused on controlling disease and increasing length of life," Gogineni says. "Patients have a much broader set of concerns, from the cost of their doctor's visits to the side effects of treatment and the emotional toll of their illness."

Sixty four percent of physicians said they supported the idea of an independent expert panel that would decide which therapies to cover, but that plan was met with resistance from patients (33 percent approved) and the general public (46 percent approved). The authors suggest this may be because physicians are more familiar with such models, which are already used for decision-making around scarce medical resources such as ICU beds and organs for transplantation. And, Gogineni notes, "distancing the locus of responsibility for access to high cost, low benefit cancer treatment may create less strain on the physician-patient relationship."

Gogineni will present the team's findings at ASCO on Sunday, June 2, 2013 in the Health Services Research poster session from 8 a.m. to noon in McCormick Place S405.

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