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Tuesday, June 21, 2016

Getting Past No in Cancer Care (U.S.)

June 20, 2016
 Office of the Chief Medical Officer, Aetna, Hartford, Connecticut, USA

 The rising cost of cancer care, and especially the rising cost of
cancer drugs, is widely held to be unsustainable. At the heart of
this debate is the belief that the benefit society is receiving is
out of register with the cost—that we are not getting good
value—and there is evidence to support that view [1]. This is
not a debate about the amazing progress that has been made
in the fundamental understanding of cancer or on the breathtaking
outcomes achieved with some of the new targeted
therapies or immuno-oncologic agents. Rather, it is the concern
that many of the new therapies being brought to market are
priced at a premium irrespective of clinical impact, resulting in
a fundamental misalignment between cost and benefit. In his
payer perspective, Dr. Newcomer [2] proposes solutions to the
frequently discussed challenge of controlling the rapidly increasing
costs of cancer care. He reviews why the free market has
failed (i.e.,because it is not really a free market).He goes onto
delineate four specific “simple” steps: (a) eliminate coverage
mandates; (b) allow for true comparative effectiveness and
cost-effectiveness research; (c) eliminate site of service differentials;
and (d) build a rapid learning system, apply it initially
to personalized medicine, and empower it to be a major tool
of clinical research. Each of these has merits, but each has
shortcomings, particularly when considering the pragmatic
perspective of “how to get it done.” It is not merely, as the author
suggests, a matter of “commitment, rigor, andc ourage.”Most of
the proposals impact the cost of cancer care but only indirectly
address the cost ofc ancer drugs. It behooves us to consider each
in turn, as well as in the context of numerous other proposed

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Oncologist 2016.
3. Thorp H, Hughes C. Trends in NHS funding:
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4. Schnipper LE, Davidson NE, Wollins DS et al.
American Society of Clinical Oncology statement: A
conceptual framework to assess the value of cancer
treatment options. J Clin Oncol 2015;33:2563–2577.
5. National Comprehensive Cancer Network. New
NCCN guidelines include evidence blocks to illustrate
value in breast, colon, kidney, and rectal
cancers. J Natl Comprehensive Cancer Network
6. Neubauer MA, Hoverman JR, Kolodziej M et al.
Cost effectiveness of evidence-based treatment
guidelines for the treatment of non-small-cell lung
cancer in the community setting. JOncol Pract 2010;
7. Zon RT, Frame JN, Neuss MN et al. American
Society of Clinical Oncology policy statement on
clinical pathways in oncology. J Oncol Pract 2016;12:
8. Kantarjian H,ChapmanR.Value ofthe340Bdrug
discount program. JAMA Oncol 2015;1:1029–1030.
9. Brower V. NCI-MATCH pairs tumor mutations
with matching drugs. Nat Biotechnol 2015;33:
10. Bach PB. Indication-specific pricing for cancer
drugs. JAMA 2014;312:1629–1630.
11. Bach PB, Mirkin JN, Luke JJ. Episode-based
reimbursement for cancer care:A proposed pilot for
Medicare. Health Aff (Millwood) 2011;30:500–509.


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