Dr. Robert A. Nagourney, MD
Evidence Based Medicine and the Cost of Cancer Care
Updated: Oct 25, 2021
Before I attended the ASCO meeting in Chicago, I penned a blog about a Forbes magazine article that described increasing restrictions placed on access to newer diagnostic tests for patients covered by Medicare.
Among the presentations that I attended at ASCO, (more to follow), was a study entitled “The cost per patient of deviations from evidence-based (EB) standards of oncology care.” The presentation caught my eye as it addressed the cost of care associated with adherence to evidence-based guidelines versus treatment plans that varied from these guidelines. Utilizing a database developed to analyze the cost of treatment, these investigators explored costs incurred when physicians used treatments that were not within the confines of the evidence-based formulae.
A total of 2,775 consecutive patients had their treatment plans (TPS) submitted and 730 (26 percent) of these patients were described as receiving, “unjustified, non-Evidence Based Treatment Plans.” The authors then examined the costs associated with these treatments. Their phraseology for treatment that varied from guidelines was those “that did not confirm to Evidence Based standards or could not be medically justified.” Apparently the practice on the part of qualified, skilled oncologists of making drug choices that vary from evidence-based medicine is synonymous with “not being medically justified.” Their conclusion “conservative estimate(s) of the average per patient overspend (first order) on inappropriate treatment validates the potential for quality care to lower cost and deliver huge value to patients, physicians and payors.”
What’s wrong with this picture?
First, clinical oncology as it is practiced today through the available guidelines (NCCN, etc.) has failed to improve 5-year survival for advanced cancer in 50 years. Thus, this “regression to the mean” thinking, if followed, would increasingly demand that medical oncologists scrupulously adhere to largely ineffective therapy guidelines.
The second problem is that this analysis provides no data on response, time to progression, survival or toxicity. For all we know, the 26 percent of patients who received non-evidence based treatment plans may have been the best responders with better survivals and lower toxicities.
Finally, in keeping with the Forbes article previously described, medical oncologists are rapidly abdicating control of their cancer patients’ treatments in favor of econometric analyses. Should this trend continue, patients may soon be forgoing the opinions of their MDs, in favor or the opinions of MBAs.