Do Oncologists Believe New Cancer Drugs Offer Good Value? Eric Nadler, Ben Eckert and Peter J. Neumann The Oncologist 2006, 11:90-95. doi: 10.1634/theoncologist.11-2-90
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Commentary Do Oncologists Believe New Cancer Drugs Offer Good Value? Eric Nadler,a Ben Eckert,b Peter J. Neumannb a
Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts, USA; b Tufts-New England Medical Center, Boston, Massachusetts, USA
Learning Objectives After completing this course, the reader will be able to: 1. Describe how academic oncologists view the costs of new treatments in their treatment recommendations. 2. Discuss academic oncologists’ perceptions of the cost and benefit of one new treatment in light of published results. 3. Describe how academic oncologists view the cost-effectiveness of new treatments relative to previously accepted standards. CME
Access and take the CME test online and receive 1 AMA PRA category 1 credit at CME.TheOncologist.com
Abstract Background. Substantial debate centers on the high cost and relative value of new cancer therapies. Oncologists play a pivotal role in treatment decisions, yet it is unclear whether they perceive high-cost new treatments to offer good value or how therapeutic costs factor into their treatment recommendations. Methods. We surveyed 139 academic medical oncologists at two academic hospitals in Boston. We asked respondents to provide estimates for the cost and effectiveness of bevacizumab and whether they believed the treatment offered “good value.” We also asked respondents to judge how large a gain in life expectancy would justify a hypothetical cancer drug that costs $70,000 a year. Using this information, we calculated implied costeffectiveness thresholds. Finally, we explored respondents’ views on the role of cost in treatment decisions. Results. Ninety academic oncologists (65%) completed the survey. Seventy-eight percent stated
that patients should have access to “effective” care regardless of cost. Implied cost-effectiveness thresholds, derived from the bevacizumab and hypothetical scenarios, averaged roughly $300,000 per quality-adjusted-life-year (QALY). Only 25% of oncologists felt that bevacizumab offered “good value.” Conclusions. A majority of academic oncologists stated that cost does not influence their clinical practice, nor should it limit access to “effective” care. Yet respondents did not consider all effective drugs to be of good value. Implied cost-effectiveness thresholds were $300,000/QALY—a value higher than the $50,000 standard often cited. A subset of oncologists were sensitive to cost, believing it should factor into clinical decisions. These findings reflect the ongoing controversies within the medical community as expensive new therapies enter the system. The Oncologist 2006;11:90–95
Introduction
treatments have entered clinical practice. The prices of many of these agents exceed $25,000 a year and result
Over the past 5 years, a number of innovative cancer
Correspondence: Eric Nadler, M.D., M.P.P., Sammons Center, Baylor University Medical Center, 3535 Worth Street, Dallas, Texas 75246, USA. Telephone: 214-370-1000; Fax: 214-820-8844; e-mail:
[email protected] Received October 14, 2005; accepted for publication December 12, 2005. ©AlphaMed Press 1083-7159/2006/$20.00/0
The Oncologist 2006;11:90–95 www.TheOncologist.com
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Key Words. Health policy • Cost-benefit analysis • Chemotherapy • Health care economic
Nadler, Eckert, Neumann
Methods Participants We surveyed 139 clinical academic oncologists at Massachusetts General Hospital and Dana-Farber Cancer Institute in Boston. Self-administered surveys were disseminated via departmental e-mail distribution lists that had been filtered to exclude oncologists not actively involved in patient care. We distributed the survey as an e-mail attachment that required physicians to print a hard copy in order to complete it. Physicians were assured of anonymity and asked to return the completed survey by mail or fax. One repeat mailing was sent 2 weeks following the initial mailing to ensure an adequate response rate. No incentives were offered to physicians to complete the survey. The survey instrument (available upon request) required approximately 5 minutes to complete.
Questionnaire The questionnaire included four sections designed to examine the relationship between the costs of cancer therapy and treatment recommendations of oncologists and to assess oncologists’ perceptions of the value offered by new cancer treatments. A final section collected demographic and profession-specific information on respondents.
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The first section of the survey asked oncologists to imagine a hypothetical, newly-approved medication for the treatment of metastatic lung cancer. Respondents were told that the new treatment cost $70,000 per year more than the standard of care treatment. They were then asked to identify the minimum survival benefit offered by the new medication at which they would be prepared to prescribe the new medication (respondents were told to assume no difference in quality of life). We presented survival benefits as categorical ranges (e.g., 2–4 months, 4–6 months), which spanned from a minimum of “1 day” to a maximum of “1 year +”. In section 2, oncologists were asked to provide estimates of the mean survival benefit and cost associated with the use of bevacizumab (Avastin®; Genentech, Inc., South San Francisco, CA) in advanced colorectal cancer (without referring to published information). We then asked oncologists whether they believed bevacizumab offered “good value for the money.” Responses to this follow-up question were captured on a modified five-point Likert scale (“Yes Definitely” to “Definitely Not”). Based on this information, we calculated implied cost-effectiveness ratios for each respondent. Section 3 of the survey explored the impact of new drug costs on oncologists’ treatment recommendations. Respondents were asked whether the overall cost of new cancer medications or the out-of-pocket costs faced by their patients influenced their treatment recommendations. Oncologists were also asked whether they believed every patient should have access to effective cancer treatments regardless of cost. Each response in this section was also recorded on a five-point Likert scale (“Strongly Agree” to Strongly Disagree”). Section 4 elicited oncologists’ beliefs about the future influence of drug costs on cancer treatment. A final statement gauged oncologists’ level of agreement (on the fivepoint Likert scale) with a statement that escalating drug costs would impose greater rationing in oncology care.
Data Analysis We used oncologists’ responses in section 1 and section 2 to calculate implied cost-effectiveness ratios (C/E ratios) using the metric of dollars per quality-adjusted-life-year ($/QALY). In section 1, incremental cost-effectiveness ratios (ICERs) were calculated for each respondent according to the following formula:
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in benefits measured in months. The dramatic tradeoff between cost and clinical benefit has made their adoption a touchstone for broader debates over appropriate resource allocation in health care. The discussion over the high costs and relative value of new cancer medications has leaped from the podiums of the American Society of Clinical Oncology and pages of medical journals onto the business sections and editorial pages of the popular press [1–3]. Oncologists play a pivotal role in treatment decisions, yet little is known about the degree to which they believe that costs matter, or should matter, in their prescribing behavior. A few studies have attempted to ascertain physician views on cost-effectiveness and rationing [4–6]. To our knowledge, none to date have focused on new drugs for cancer, nor have they attempted to capture oncologists’ cost-effectiveness thresholds (i.e., beliefs about society’s willingness to pay) for new interventions. In this paper, we report on a survey administered to practicing medical oncologists. Our goal was to understand oncologists’ views on the costs and value of new cancer agents and whether they believe there is a point at which incremental improvements in life expectancy do not justify the extra spending involved.
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Do New Cancer Drugs Offer Good Value?
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where ΔCost = $70,000; LE = Life expectancy; the midpoint of the selected survival benefit range was used (i.e., if a respondent selected “2–4 months,” a midpoint of 3 months was used); QAo = Quality adjustment = 1 (i.e., no change in quality of life [QoL]). A sample calculation (assuming the respondent selected a survival benefit range of 2–4 months) follows:
ICER
In our determination of this implied C/E ratio, we assumed the standard of care treatment would be one full year.
Table 1. Description of sample Respondent characteristic (n = 90)
%
Overall Gender Male Age
