Can the 4 Ps Devise Interventions to Reduce the Financial Toxicity of Cancer?

There is no arguing that cancer care can drain an individual’s or their family’s coffers. Now that this has been reaffirmed by various sources, a discussion at the 2017 American Society of Clinical Oncology Annual Meeting addressed the practical solutions to address the financial toxicity of cancer care and identified leads for future intervention studies aiming to prevent or reduce this burden.

The session, chaired by Yousuf Zafar, MD, MHS, associate professor of medicine, Duke University Medical Center, included the 4 Ps:

• Pharma: Matthew Shaulis, president, North America Oncology, Pfizer
• Payer: Lee N. Newcomer, MD, senior vice president, Oncology and Genetics, UnitedHealth Group
• Physician: Leonard Saltz, MD, chief, gastrointestinal oncology service and head of colorectal oncology section, Memorial Sloan Kettering Cancer Center
• Patient: Shelley Fuld Nasso, MPP, chief executive officer, National Coalition for Cancer Survivorship.

Zafar asked the panelists to provide their 1 clear solution to this problem of financial toxicity in oncology…without using slides.

Shaulis said that Pfizer shares the goal of improving quality of care for patients. “We need to focus and prioritize. We have to tailor market-based solutions to ensure continued innovation,” Shaulis said.

A longitudinal actuarial study conducted by Milliman and sponsored by Pfizer among cancer patients identified a 500% increase in care costs in the first month, mainly due to diagnosis and initial treatment, Shaulis told the audience. The costs were highest for colorectal cancer and lung cancer, followed by breast cancer. “However, consistent across the numerous studies was that cancer drugs accounted for only 20% of the total cost of care.” From a more holistic perspective, we also should include peripheral costs such as loss of work for the patient and caregivers, Shaulis added.

“Market-based solutions are important because innovation and choice are necessary to ensure support for new medications,” Shaulis said, and competition paves the path to affordable access, investment in data, and novel reimbursement mechanisms.

“As a federal or commercial insurance program, you are mandated to provide coverage to all FDA-approved drugs. So I propose ending the mandate for providing coverage for each and every drug that is out there even if it does not provide value,” said Newcomer, the payer voice in the discussion.

“When you make a value decision, you are using a set of principles that others may not agree with,” he said. “But with the mandate on cancer drugs, we cannot use the value quotient."

He referenced a retrospective study by UnitedHealth Group that was presented at the meeting using data from stage 4 patients with metastatic non-small cell lung cancer (mNSCLC). The study found that patients treated with the 5 most commonly prescribed first-line therapies for mNSCLC have much shorter duration of therapies (52-76 days) than reported in published clinical trials with a significant risk of hospitalization (18% to 30%) and at substantial cost ($34,971 to $108,100).

“This is an easy value decision to make, but the mandate creates a barrier,” Newcomer said. He concluded that when there’s competition among multiple regimens that give us the same results, we need to have the flexibility to make those value decisions.

“For me as an oncologist, my 1 solution is to know what the cost of the treatment,” said Saltz. “What we need is an informed discussion among stakeholders and for that we need everyone to have all the information."

He emphasized that he was talking about cost, not “value.” Saltz believes that cost and value are not the same. “They are related. They are inversely proportional,” he said.

However, we cannot put a number on value and we cannot provide an accurate qualitative context to it. Saltz drove home the point that while physicians consider it their duty to provide patients an accurate estimate of toxicities and the adverse effects, discussions on the impact on patient finances “is also a part of our job. We cannot be uncomfortable about this.”

“I’d also argue that as academicians, we could be considering costs in our trials. When we look at benefit (such as overall survival and disease-free survival) we could also include cost in the equation,” he said.

Nasso said that patients want to live their life well during and after treatment. They want to be functional and working and want to understand the impact on their families during treatment. “So, the burden of finances needs to be a part of the overall impact on the patient, in addition to the disease being treated,” she said.

Care planning, Nasso believes, should not be a checkbox, rather a conduit to initiate a discussion on the topic. This should include conversations around out-of-pocket costs as well as indirect costs of the treatment: hospital visits, work loss for self and family, and the like. “Affordability should not be on the map at all, but that’s where we currently are,” Nasso said.

She emphasized the importance of a cancer care plan for the patient to revisit after their conversation with the care provider and added that the healthcare system should reimburse this process through incentives. She also urged physicians to step up and be more proactive on this front.

“I’d like to see a system where we can help patients go through this process.”