Spending More for Cancer Care Does Not Reduce Mortality

Growth in healthcare spending in the United States continues to outpace growth in European countries that enjoy a similar standard of living.

Growth in healthcare spending in the United States continues to outpace growth in European countries that enjoy a similar standard of living. Compared with the nations that make up the Organisation for Economic Co-operation and Development, the US spends a higher percentage of its gross domestic product on health and ranks first in per capita spending on healthcare and pharmaceuticals.¹Cancer is one area where healthcare costs continue to soar in the US and abroad.

In 2011, the annual cost of cancer care in the US was estimated at around $124 billion and was projected to top $173 billion by 2020.²Although oncologists do not question the value of prolonging lives and relieving suffering, some are questioning how much proverbial bang for the buck patients are receiving from the new oncology drugs that have driven much of the growth in per-patient costs.^3-5

The monthly price tag for 9 of the 12 new cancer drugs the US Food and Drug Administration (FDA) approved in 2012 exceeded $10,000.3 In looking at targeted drugs, Kantarjian et al reported annual costs ranging from $61,000 per year for lapatinib to $270,000 per year for brentuximab.³Only 3 of the 12 cancer drugs approved in 2012 prolonged survival; and of those 3 drugs, only 1 extended survival by more than 2 months.³As the population ages, the number of US cancer survivors is expected to grow from 14.5 million in 2014 to 18 million in 2020—an almost 25% increase.^2,6As a result, many oncologists fear that the current cost of treating cancer in the US is unsustainable.^3-5

Two Dartmouth researchers decided to analyze whether or not the US reaps greater benefit from spending more on cancer care than its counterparts in Western Europe.⁷Using demographic data and national data on healthcare expenditures for 20 Western European countries plus the US, Soneji and Yang estimated the amount each country spent between 1982 and 2010 for each of 12 cancer types. Next, they looked at trends in cancer mortality for each country.

In a press release at the Dartmouth website, lead author Samir Soneji, PhD, an assistant professor at Dartmouth's Geisel School of Medicine and the Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, Pennsylvania, described the significance of the findings. "Our results suggest that cancer care in the US did not always avert deaths compared to Western Europe and, when it did avert deaths, it often did so at substantial cost," said Soneji.⁸"The greatest number of deaths averted occurred in cancers for which decreasing mortality rates were more likely to be the result of successful prevention and screening rather than advancements in treatment."⁸

The study⁷found that the US spent $435 billion more than Western Europe on breast cancer, resulting in 67,000 fewer breast cancer deaths, for an incremental cost to quality of life-year (QALY) saved of $402,000. For colorectal cancer, the US spent $326 billion more than Western Europe, averting 265,000 deaths, for an incremental cost-to-QALY ratio of $110,000. The $435 billion in increased spending on prostate cancer in the US averted 60,000 deaths for a cost-to-QALY ratio of $1,979,000. For lung cancer, the United States spent $406 billion more than Western Europe, yet counted 1,120,000 more deaths. This corresponded with an estimated loss per QALY of $19,000.

Historically, the benchmark for assessing value has long been $50,000 per QALY, although some have suggested raising the QALY threshold in the US to $100,000 or $150,000, or as high as $300,000.9 However, Soneji and Yang’s study shows that the incremental cost per QALY in the US for several of the cancers evaluated would have exceeded even these higher thresholds.⁷

Table. Deaths Averted and Cost Per QALY Saved in the United States by Cancer Type

Type of Cancer

Deaths Averted

Incremental Cost/QALY Saved ($)

Breast

66797

402369

Cervical

4354

-855019

Colorectal

264632

110009

Hodgkin lymphoma

4859

156045

Leukemia

-64530

-30790

Lung

-1119599

18815

Melanoma

-39144

-136592

Non-Hodgkin lymphoma

-164429

-41362

Prostate

59882

1978542

Stomach

621820

4635

Testis

3372

222839

Thyroid

18320

139681

In trying to determine reasons for the differences in mortality between the US and Western Europe for some cancers, the researchers found earlier adoption of trastuzumab in the US may have contributed to the lower breast cancer mortality rate but that greater reliance on mammography was unlikely to have played a role.7 Declines in prostate cancer deaths in the US and Europe were likely attributable to treatment advances, but the reason for the lower prostate cancer mortality rate in the US was unclear. Heavier use of colorectal cancer screening in the US appeared to account for the nation’s much lower mortality rate for this cancer. The US also averted 621,820 more stomach cancer deaths than Western Europe, which the authors suggested may be due to lower rates of Helicobacter pylori infection and more sanitary food preparation in the country. The incremental cost-to-QALY ratio in stomach cancer was $4,635, well within the $50,000/QALY threshold. Other cancers where higher US spending did not avert deaths included melanoma, non-Hodgkin lymphoma, and leukemia. Overall, the study showed spending more on treatment did not always translate to better outcomes. However, increased spending on screening and prevention typically provided significant benefits for patients at a more favorable cost-to-QALY ratio.⁷

As cancer therapy shifts from monotherapy regimens to combinations of drugs designed to inhibit different targets within a tumor simultaneously or to regimens that combine a targeted therapy with immunotherapy, the additional costs may help drive the growing burden of healthcare in the US to unsustainable levels.³Groups like the American Society of Clinical Oncology (ASCO) and the American Board of Internal Medicine Foundation are encouraging all physicians to include cost-effectiveness as a factor in planning treatment now, before care becomes unaffordable.⁴As ASCO notes on its website, "We should recognize that best use of limited resources does not have to necessarily compromise optimal treatment of every patient. The two goals are parallel and not in opposition."⁴

References

1. OECD. OECD Health Statistics 2014: How does the United States compare? http://www.oecd.org/unitedstates/Briefing-Note-UNITED-STATES-2014.pdf. Accessed March 10, 2015.
2. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the Cost of Cancer Care in the United States: 2010-2020.J Natl Cancer Inst. 2011;103:117—128.
3. Kantarjian HM, Fojo T, Mathisen M, et al. Cancer drugs in the United States: Justum pretium—the just price.J Clin Oncol. 2013;31:3600-3604.
4. ASCO in action brief: value in cancer care. http://www.asco.org/advocacy/asco-action-brief-value-cancer-care. Published Janaury 21, 2014. Accessed March 10, 2015.
5. Experts in Chronic Myeloid Leukemia. The price of drugs for chronic myeloid leukemia (CML) is a reflection of the unsustainable prices of cancer drugs: from the perspective of a large group of CML experts.Blood. 2013;121:4439-4442.
6. American Cancer Society. Cancer Treatment & Survivorship Facts & Figures 2014-2015. Atlanta: American Cancer Society; 2014.http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-042801.pdf. Accessed March 10, 2015.
7. Soneji S, Yang J. New analysis reexamines the value of cancer care in the United States compared to Western Europe. Health Aff (Millwood). 2015;34:390-397.
8. US spends more on cancer care, saves fewer lives than Western Europe [press release]. http://cancer.dartmouth.edu/about_us/newsdetail/73137. Published March 2, 2015. Accessed March 10, 2015.
9. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness--the curious resilience of the $50,000-per-QALY threshold.N Engl J Med. 2014;371:796-797.