May 26, 2010 -- Annual costs of cancer care are expected to rise to more than $173 billion dollars by 2020, a nearly $70 billion increase since 2006, according to the National Cancer Institute.
But limiting chemotherapy for patients with metastatic or recurrent cancers would not only dramatically cut exorbitant medical costs but would also improve a patient's quality of life, two oncologists suggest in a paper published Wednesday in the New England Journal of Medicine.
While cycles of chemotherapy vary depending on the type of cancer, authors Dr. Thomas Smith and Dr. Bruce Hillner suggest that oncologists limit treatment for patients who are not responding to three cycles of chemotherapy.
"We shouldn't give chemotherapy or radiation unless there's a reasonable reason," said Smith. "This money could be applied to better clinical trials, better medicines, things that would buy value."
This recommendation is one of 10 Smith and Hillner outlined as a response to a challenge posed by a colleague to suggest changes in the practice of medical oncology that could save the nation billions of dollars.
Current guidelines by the American Society of Clinical Oncologists already recommend stopping treatments that do not seem to benefit the patient. But many oncologists fail to put these guidelines into practice, said Smith, a medical oncologist and palliative care specialist at Virginia Commonwealth University's Massey Cancer Center.
Although chemotherapy may no longer be beneficial for end stage cancer patients, many oncologists choose to continue treatment, said Smith.
Previous studies suggest that as many as 20 percent of patients are getting chemotherapies in their last two weeks of life. Instead, Smith suggests spending the time beforehand to discuss end-of-life care with patients.
"When you've had that conversation you've given people help with that transition," said Smith, who acknowledged that the conversation with patients and families can be challenging. "We can explain to people what they have, set medically reasonable goals, have honest communication and choose less expensive drugs."
While many experts agree with the position, they said the focus should be less about preserving costs than about improving a patient's quality of life.
"Chemotherapy may seem to marginally increase survival rates, it substantially increases the risk of other potentially serious health problems," said Greg Anderson, founder of the Cancer Recovery Foundation International.
Some side effects of chemotherapy and radiation include hair loss, fatigue and memory loss.
Some studies have shown that implementing palliative care not only improves quality of life but also prolongs survival.
But the paper suggests that some physicians intentionally do not provide end-of-life discussion or palliative care because they are not compensated for it.
Dr. David Cronin, associate professor of surgery at the Medical College of Wisconsin, disagreed. Many physicians abandon treatments and switch to palliative care options when their patients have little chance of survival.
"This is good medicine, this is what physicians are supposed to do, this is compassionate medicine, this is the responsibility of physicians," said Cronin.
The discussion circles back to communicating the "futility and toxicity" of treatment for these patients, said Dr. Anthony Elias, director of the breast cancer research program at the University of Colorado Health Sciences Center in Denver.
"Would you prefer to die in some comfort with hospice and good supports for your family, or do you want to suffer the side effects of ineffective treatment?" said Elias. "I would not place it in terms of cost or affordability."
However, Smith said that oncologists should be held responsible for the issue of cost, not patients. In the case of cancer care, increasing a patient's quality of life and reducing the cost of care go hand in hand, said Smith. One should not be considered without the other, and it's up to oncologists to take the lead, he said.
"I think oncologists feel that someone else is driving cancer costs up. But in fact, it's us," said Smith.
"We're ordering the tests. We're adding expensive supportive care drugs when they won't extend survival."