Dr Sara J. Grethlien: What Does "Value" Really Mean in Cancer Care?

Sara Grethlien, MD, MBA, FACP, executive medical director of the Swedish Cancer Institute at Swedish Medical Center, spoke to what value truly means in cancer care and the challenges of evaluating its accompanying metrics. The concept of value in health care remains a prominent discussion as oncology anticipate the developments of novel, high-cost therapeutics transforming the treatment landscape. Of chief concern, Grethlien emphasizes, are future opportunities for policy reform.

These topics and more were explored at the final Institute of Value-Based Medicine event of 2024, held in Seattle, Washington, in December.

This transcript has been lightly edited.

Transcript

How do you define “value” in cancer care? Which metrics or frameworks would you say measure “value” most effectively?

I think value is tough to measure accurately in cancer care, quality adjusted life years is probably the one that makes the most sense to me, because it is patient centric, and years of life with a low quality of life are not what we're trying to achieve. So, I'm a fan of quality as 1 of the metrics for value. I think that we also have to pay attention to what the alternatives are in the decisions that we make. So, if there is an A vs B option, we need to be looking at the interval difference in survival or disease control survival, and use that to compare with the cost as best we can measure it. So that's not exactly a quality adjusted life here, but it's an incremental benefit versus cost. And I think that's really going to turn out to be one of the harder things to measure, but the more important things that we have to measure.

What strategies can ensure that novel, high-cost cancer treatments, such as cell therapies and emerging gene therapies, remain accessible and sustainable within health care systems?

I think one of the critical things we have to focus on is how we can democratize, how we can extend the quaternary care appropriately. And we could start with, “How do we deliver it across disparities of geography, of demographics?” Obviously, those are key things for us to keep in mind. But I think we need to be pushing earlier in the chain. We need to be pushing for the inclusion of these distribution studies in clinical research in policy. For example, CAR T is a very exciting advance over the last several years and is going to be getting more and more important in solid tumors. Up until now, it's predominantly been for hematologic malignancies. This is autologous therapy that requires leukapheresis and a personalized plan of care, a personalized development of a product used for a single patient. If we can support, through government grants, through research initiatives, through policy, the development of off-the-shelf variants that will allow us to cut cost and cut the requirement for things like leukapheresis, which can be a choke point in the individualized care.

So, I think we have to start back earlier than once the therapies are developed, and encourage and support—financially and through policy—the development of therapies that can be more widely applied. I think about rural cancer care as an example, and there's no opportunity for patients in rural communities to participate in care that requires apheresis when they're already struggling to have access to things like blood transfusions. As we think about disparities across demographics, across socioeconomics, we also have to think about geography and how we can develop therapies that are more readily applied.