It is the best of times and the worst of times in oncology. It is the best of times, because the basic understanding of cancer biology has advanced dramatically and is resulting in real changes to the way we treat cancer. It is the worst of times, because the price tag may not fit in the budget.
There is little question that cancer care is expensive, and that the cost trajectory is unsustainable. And the reason the cost of care is so expensive is multifactorial, and certainly not just because of the cost of chemotherapy. But many of the new breakthrough agents are being launched at a very high price.
Payers are in an awkward position with respect to these prices, because of the general paradigm that FDA-approved cancer therapies are “covered benefits,” and there is little or no negotiation on price. This is true whether the new therapy truly produces a great outcome or not: coverage is independent of value.
A long history exists in Europe of formal value assessment that informs coverage policy, like NICE (National Institute for Health and Care Excellence), but enthusiasm has lagged for this approach in the United States. In the past several months, a groundswell of support has taken place for oncologists tackling this value assessment. Exactly why this has occurred is subject to debate, but issues regarding limited access, financial toxicity experienced by patients, or just fairness have all contributed.
The transparent, objective processes of evaluation used by the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and Memorial Sloan Kettering Cancer Center are all constructs to bring value into the discussion. The individual tools are all slightly different and represent an initial iteration of how technology assessment could be implemented. They all use the components of efficacy and toxicity in the context of cost. And they are all imperfect.
They do not formally consider patient preferences. They do not consider the total cost of care. But they do begin a dialogue that should occur between patients and physicians as part of shared decision-making. These tools also should prompt a dialogue between society and the innovators about the fair price of innovation. And these tools should stimulate thinking among drug manufacturers about maximizing the therapeutic benefit of the new medications being brought to market.
The willingness of physicians to act as stewards of scarce healthcare resources will benefit everyone. Arguing about how expensive it is to develop a drug, and setting the price according to what the market will bear, benefits no one. And patients with cancer need new approaches that improve their outcomes at a fair price.