The cost of cancer care is rising and a review of the research literature on cancer care in Australia can teach many lessons to us in New Zealand.
In Australia real costs for cancer per person (adjusting for inflation) have more than doubled in the last 25 years. The drivers are multifactorial but due in part to upward trends in diagnosis (often the result of new diagnostic methods and screening programmes), the rising cost of cancer pharmaceuticals, and increasing expectations.
The largest costs are treatment costs. Taking Australia as an example, hospital services, including day admitted patients (usually for chemotherapy), account for 79% of cancer costs. The number of approved cancer medicines has doubled since 2013.
Rising costs in health care are not sustainable. We need better efficiency.
Efficiency in health is about making choices that maximise the health outcomes gained from the resources allocated. And it seems like there are a number of different ways that we could target the cancer care pathway to improve efficiency. However, this can only work if the entire care path is looked at as a whole, and the notions of funding silos are dispensed with.
Prevention
For example, healthy lifestyle and regular screening could prevent an estimated one third to one half of all cancers, but presently, only single-figure percentages of cancer funding target prevention.
This is despite the modelled return on investment for cancer prevention programmes, which is often $3–$4 per $1 spent. As an added bonus, cancer prevention can also reduce the burden of other diseases (e.g. reducing inactivity can also benefit diabetes and heart disease).
Screening
Participation rates in screening programmes are generally poor. For many programmes 40–60% is considered a good uptake. This is inadequate. Increasing screening rates is likely to increase the effectiveness of screening programs. And modelling suggest in some cases that sufficient uptake can lead to future cost savings.
We should also do more to ensure that patients who are up-to-date with screening are not re-screened (e.g. those who have had recent colonoscopy) and ensure that follow-up after screening is based on guidelines. It often isn’t.
Diagnosis
Over-diagnosis is becoming a problem in the cancer care path. Breast screening often reveals anomalies that are not cancer. Artificial intelligence systems used to augment physician diagnosis could curb this.
Not only is there evidence from a 2015 systematic review that prostate cancer screening is not cost effective, but prostate screening with PSA can lead to cancer diagnoses (and treatment) in men whose tumors will never cause them problems.
There has also been a rapid spike in thyroid cancer diagnoses, leading to an increase in thyroid surgeries, for example in Australia, but no corresponding change in deaths from thyroid cancer.
Reducing unnecessary detection and a conservative approach could lead to millions of dollars in savings and reduced harms to patients from over-diagnosis.
Treatment
The cost of treatment is also a problem. In Australia, cancer accounts for 6.6% of hospital costs, but the cost of cancer medication is one sixth of the total pharmaceutical budget. The 10-fold increase in cost of these medicines over 10 years is a serious threat to patients and health systems.
We could decrease the costs of cancer medications by modifying prescription habits, considering treatment costs in professional guidelines, disinvesting in medicines that have not proven cost-effective in the real world, improving patient selection, and increasing use of generics.
There is evidence of over-treatment. A watch and wait approach is appropriate for many prostate cancers in the early phase, or active surveillance of low risk patients could reduce costs and is often clinically reasonable.
We could consider pharmacist review of prescriptions to avoid the risk of adverse drug reactions (and the associated treatment costs). We could do more to ensure there are no unjustified variations in clinical practice.
Follow-up
We should ensure that patients have a written care plan and are not receiving follow-up from multiple overlapping providers. Also, follow-up should be guideline based. Some studies indicate that less than half of bowel cancer patients received guideline-based follow-up colonoscopy.
We could make more use of primary care where studies have not shown hospital follow-up to be any more effective in detecting recurrent disease.
Traditional follow-up focuses on detecting cancer recurrence, but this can fail to adequately address many survivors’ concerns. Getting back to work (and being supported to do so is important to reduce the societal costs of cancer. Occupational therapy may be important in facilitating this.
Palliation
Palliative care costs less than hospital care and is under-utilised. But to optimise the use of out-of-hospital palliative care, patients need to have accurate prognostic awareness, allowing them to make informed choices. This requires important conversations with treatment providers. Lack of a palliative care plan leads to unnecessary emergency room visits and hospital admissions that are primarily palliative.
Research
Research costs could also be streamlined. We should ensure that the cancer research being undertaken reflects the burden of cancer. Lung cancer has the greatest burden of all cancer (especially in terms of years of life lost) and yet there is far less lung cancer research than this burden demands.
Cancers including leukaemia, breast, ovary, liver and skin, often receive proportionately more funding than their disease burden. Prevention, cancer control, and survivorship research could be funded more. This is because effectiveness in these components of the care path lead to downstream cost savings and potentially increased social productivity.
Summary
Overall, it looks like prevention and early detection are generally underfunded. There is also scope to increase participation in screening programs.
The rapidly rising costs of treatment, including medications, need to be curtailed through wise practice, and new models of care, that prioritise prevention, screening, surveillance, guideline and evidence-based follow-up, return to work, and palliative care where appropriate.
Reducing the cost of medications is a high priority, with large potential cost savings. The focus should be on treatments that are proven to work well in the real world rather than on increasing use of expensive drugs with marginal benefit.
We need a long-term focus including a culture of change and workforce planning. Further efficiencies might be gained through initiatives such as: Choosing Wisely, addressing variations in process and treatment, minimising non-adherence to treatment, avoiding communication failures, ceasing ineffective interventions, coordinating care, reducing admissions, using generics, negotiating price, reducing adverse events, taking a societal perspective of costs, and considering upfront cost versus long-term impact.
Further Reading
Ananda, S., Kosmider, S., Tran, B., Field, K., Jones, I., Skinner, I., . . . Gibbs, P. (2016). The rapidly escalating cost of treating colorectal cancer in Australia. Asia-Pacific Journal of Clinical Oncology, 12(1), 33-40.
Chen, C. H., Kuo, S. C., & Tang, S. T. (2017). Current status of accurate prognostic awareness in advanced/terminally ill cancer patients: Systematic review and meta-regression analysis. Palliative Medicine, 31(5), 406-418.
Colombo, L. R. P., Aguiar, P. M., Lima, T. M., & Storpirtis, S. (2017). The effects of pharmacist interventions on adult outpatients with cancer: A systematic review. Journal of Clinical Pharmacy and Therapeutics, 42(4), 414-424.
Cronin, P., Kirkbride, B., Bang, A., Parkinson, B., Smith, D., & Haywood, P. (2017). Long-term health care costs for patients with prostate cancer: a population-wide longitudinal study in New South Wales, Australia. Asia-Pacific Journal of Clinical Oncology, 13(3), 160-171.
Doran, C. M., Ling, R., Byrnes, J., Crane, M., Shakeshaft, A. P., Searles, A., & Perez, D. (2016). Benefit cost analysis of three skin cancer public education mass-media campaigns implemented in New South Wales, Australia. PLoS ONE, 11 (1).
Furuya-Kanamori, L., Sedrakyan, A., Onitilo, A. A., Bagheri, N., Glasziou, P., & Doi, S. A. R. (2018). Differentiated thyroid cancer: Millions spent with no tangible gain? Endocrine-Related Cancer, 25(1), 51-57.
Gordon, L. G., Tuffaha, H. W., James, R., Keller, A. T., Lowe, A., Scuffham, P. A., & Gardiner, R. A. (2018). Estimating the healthcare costs of treating prostate cancer in Australia: A Markov modelling analysis. Urologic Oncology: Seminars and Original Investigations, 36(3), 91.e97-91.e15.
Jefford, M., Rowland, J., Grunfeld, E., Richards, M., Maher, J., & Glaser, A. (2013). Implementing improved post-treatment care for cancer survivors in England, with reflections from Australia, Canada and the USA. British Journal of Cancer, 108(1), 14-20.
Langton, J. M., Blanch, B., Drew, A. K., Haas, M., Ingham, J. M., & Pearson, S.-A. (2014). Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: A systematic review. Palliative Medicine, 28(10), 1167-1196. doi:10.1177/0269216314533813
Lao, C., Brown, C., Rouse, P., Edlin, R., & Lawrenson, R. (2015). Economic evaluation of prostate cancer screening: A systematic review. Future Oncology, 11(3), 467-477.
Leggett, B. A., & Hewett, D. G. (2015). Colorectal cancer screening. Internal Medicine Journal, 45(1), 6-15.
Ma, C. K. K., Danta, M., Day, R., & Ma, D. D. F. (2018). Dealing with the spiralling price of medicines: issues and solutions. Internal Medicine Journal, 48(1), 16-24.
MacLeod, T. E., Harris, A. H., & Mahal, A. (2016). Stated and Revealed Preferences for Funding New High-Cost Cancer Drugs: A Critical Review of the Evidence from Patients, the Public and Payers. The Patient, 9(3), 201-222. doi:10.1007/s40271-015-0139-7.
Olver, I. (2018). Bowel cancer screening for women at midlife. Climacteric, 21(3), 243-248.
Shih, S. T., Carter, R., Heward, S., & Sinclair, C. (2017). Economic evaluation of future skin cancer prevention in Australia. Preventive Medicine, 99, 7-12.
Wait, S., Han, D., Muthu, V., Oliver, K., Chrostowski, S., Florindi, F., & de Lorenzo, F. (2017). Towards sustainable cancer care: Reducing inefficiencies, improving outcomes—A policy report from the All.Can initiative. Journal of Cancer Policy, 13, 47-64.
Youl, P., Baade, P., & Meng, X. (2012). Impact of prevention on future cancer incidence in Australia. Cancer Forum, 36(1).
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