The soaring costs of cancer care in this country give us a useful lens with which to look more closely at how high the stakes have become for health care reform. As described in my recent book, The Cancer Generation: Baby Boomers Facing a Perfect Storm, cancer will soon outstrip heart disease as the nation’s leading cause of death. The American Cancer Society estimates that, over their lifetimes, 45 percent of men and 38 percent of women will develop cancer.

While diagnostic methods and treatments have improved greatly in recent years, the costs of cancer care are growing faster than most other parts of our health care system. It is no longer unusual for chemotherapy to cost more than $100,000 a year. And the costs of cancer care can be expected to rise even faster over the next few years, when nanotechnology (involving molecular-sized particles) takes methods of diagnosis and treatment to a new level.

All of this forces us to confront long-neglected questions, such as whether or not health care is a right or a privilege based on ability to pay, societal vs. individual priorities in health care, the role of government vs. the market in the delivery of care, and whether we can ever rein in the costs of health care?

An excellent recent article by two researchers at the National Cancer Institute brings urgency to these questions. Writing in the Journal of the National Cancer Institute, Tito Fojo and Christine Grady illustrate the cost problem by noting that cetuximab (Erbitux), a treatment for patients with non-small cell lung cancer, adds just 1.2 months in survival at a cost of $80,000.

They conclude: “We must deal with the escalating price of cancer therapy now. If we allow a survival advantage of 1.2 months to be worth $80,000, and by extrapolation survival of one year to be valued at $800,000, we would need $440,000 billion annually – an amount nearly 100 times the budget of the National Cancer Institute –to extend the life of the 550,000 Americans who die of cancer annually. And no one would be cured.…The current situation cannot continue.”

Fojo and Grady suggest some useful standards for comparative effectiveness research, which together could move us toward better evidence:

• Comparative effectiveness studies that are powered to detect a survival advantage of two months or less should only test interventions that would be marketed at a cost of less than $20,000 for a course of treatment. (They base that figure on the experience of other developed countries that pay less than $129,000 a year for an extra year of life.)
• Drugs found to be active in one subset of patients should be advocated, approved, and prescribed only for that subset of patients.
• If a drug is approved by the Food and Drug Administration only for first-line treatment, it should not be used as a second-line treatment without supporting evidence.
• Use of marginally effective treatments for advanced cancer should be discouraged; emphasis should be first on quality of life, and then on cost.
• Toxic effects should be examined more rigorously for therapies of marginal benefits.

The very word “cancer” evokes anxiety and fear among so many people. Payers face a “taboo” that makes it difficult to deny payment for treatments, even when they are of limited or no benefit. Oncologists find themselves in a market-based culture where “anything at all costs” tends to prevail, and they are often reluctant to be “the bad guy” by denying patients the option of treatment when it is likely to be ineffective or even futile. In a survey, four of five oncologists in Boston said they did not believe that costs should be a deciding factor in treatment decisions and that costs in the range of $300,000 a year were acceptable.

Comparative effectiveness research is an element in the current proposals in Congress for health care reform. The House Bill (H.R.3200), for example, includes a provision to establish a new federal agency to make science-based recommendations on the comparative effectiveness of health care services. And, true to form, conservative opponents are quick to attack these proposals on the unfounded grounds of too much government control, a slippery slope to socialism, loss of choice, adverse impact on innovation, and rationing.

We know enough about the failures of comparative effectiveness research in the past to try to avoid problems in the future. When such studies find that a drug or medical device is ineffective or even harmful, manufacturers and providers fight back in an effort to retain their markets.

As one example, when the Agency for Health Care Policy and Research in the 1990s found that spinal fusion surgery had higher costs and more complications than other back operations, it recommended nonsurgical approaches to back pain. The political backlash from industry and the North American Spine Society resulted in sharp cuts in funding for the agency and removal of the word “policy” from its name – it was reconstituted as the Agency for Health Care Quality and Research.

Any new federal agency that oversees this research must be independent, science-based, adequately funded, and protected from lobbyists and political interference. But even if we are successful in establishing a new agency with the mandate and funding to evaluate the comparative effectiveness of medical technologies, there is still a gaping gap between recommendations and effective health care policy. For example, many studies have shown that physicians often do not follow clinical practice guidelines, current reimbursement and coverage policies encourage early adoption and overutilization of new technologies of unproven benefit, our physician work force is skewed toward specialists practicing high-technology medicine of uneven value, and we have no effective methods of accountability or cost containment built into our fragmented multipayer financing system.

So just expanding comparative effectiveness research, even if it is well done this time, will fail once again to contain health care costs unless we attend to other fundamental problems of the system. We also need to eliminate the wasteful bureaucracy of the private insurance industry; establish a not-for-profit single-payer system of national health insurance (Medicare for all), coupled with the strengths of our private delivery system; revise reimbursement policies to rebuild primary care and reduce perverse incentives to over-utilization; address ethical issues in practice and research; and empower regulators to provide more effective oversight of best practices and products.

All that can be done, if we have the political will to assert the public interest over the self-interest of industry stakeholders in the medical-industrial complex. This will be an uphill battle, since our costs are their revenue and shareholder returns.

John Geyman, M.D. is a family physician and professor emeritus of family medicine at University of Washington. He is the author of several books, including The Cancer Generation and Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It. jgeyman@u.washington.edu; 360–378-6264.