The True Cost of Cancer

In 2009, ASCO suggested that one method of curbing the cost of cancer care is to have oncologists incorporate this into patient discussions.

Video from 2009 ASCO Annual Meeting regarding discussing cost of care can be viewed here: "Discussing the Cost of Care with Patients with Cancer: What Can We Tell Them? What is the Goal?"

Yet, many oncologists remain hesitant to have these conversations.

How do patients feel about it? One survey found 78 percent of patients said they were comfortable talking about the cost of cancer care with their doctor.

In my own experience, I have found that patients are actually very concerned about cost. A patient once told me that she knew her husband was dying, and the exorbitant cost of aggressively treating widely metastatic cancer with a less than one year survival rate at best was exhausting their retirement benefits.

She also was concerned that they would be contributing to Medicare's strained finances. She and her husband felt that to continue treatment that would not be curative would possibly keep necessary funding from someone else, someone who could be cured. Besides, she pointed out, he has felt terrible since starting chemotherapy, so why are we doing it? It amazes me when patients are practical in the face of death, but they were right. The treatments we were doing were causing more distress than comfort, and were very expensive.

One elderly couple said they had lived good lives, and had worked hard to save to have something to leave their children. They didn't want to spend it on treatments that would prolong their lives four months but cost $80,000.

I have had many patients, especially the elderly, who say over and over again that they want the limited federal healthcare dollars to be spent to the best advantage for everyone. They read the news. They pay taxes. They know what is going on in the world. They aren't taking this decision lightly. Sometimes they are tearful. But they are also realistic.

I'm certainly not saying that we should deny anyone a treatment solely because of its cost, but we can't ignore that there are times when we are prolonging survival for a tiny fraction of time. Could it be another case of "just because we can doesn't mean we should"?

Sometimes more expensive doesn't mean better. Cancer care isn't always a "get what you pay for" kind of thing. Unlike so many other products, sometimes the least expensive options are the most beneficial for the patient. The New England Journal of Medicine published a study in 2010 that revealed that patients with metastatic non-small-cell lung cancer who received early palliative care had significant improvements in quality of life.

They also had longer survival and less aggressive care at the end of life. While this study was not about cost of care, clearly comfort care is less expensive than aggressive care, and patients lived longer and better. Who could deny they got the best care, despite the probably significantly lower price tag?

In my own experience, this has been true; the above mentioned cancer patient chose palliative care and transitioned to hospice. Unlike the frequent readmissions the patient had previously experienced while undergoing treatment, he was able to feel better, avoid hospitalization, and enjoy quality time with his family. While under treatment, he appeared at death's door.

Many bedside vigils were held, anticipating he wouldn't make it through the night. Once comfort measures were instituted, going home was possible due to better symptom control and lack of chemotherapy side effects. The end of his life was as he and his family wanted: at home, doing the things he wanted to do. An added bonus was that he was able to leave behind some retirement money for his wife, something that weighed heavily on both of their minds.

There may be times when the most expensive treatment out there really is the best option. And there may be times when it isn't. True informed consent has to take into account more than the side effects and proposed treatments; it also involves risk, benefit, and cost.

Another reason to openly discuss cost of care with patients is what we may learn about their own financial concerns. A recent survey found that 40 percent of individuals surveyed experienced at least one serious financial hardship related to treatment. Most of these patients did not discuss the cost of care with their doctors.

Of the patients surveyed, 5 percent skipped treatments, and 7 percent refused treatment because the cost was prohibitive. Discussing costs of care with these patients may have helped identify problems early. This would have provided opportunity to address the financial barriers to care, and help patients access needed treatment.

The bottom line? We cannot shy away from discussing expense and out-of-pocket costs with patients because we are uncomfortable. These frank discussions can help avoid futile care and, in some cases, improve access to care.