Chicago, IL—The issues underlying financial toxicity are undoubtedly complex, but for oncologists looking to help their patients cope, simply noting the cost of treatment from the outset may be the best place to start. As the cost of cancer care continues to rise, greater transparency throughout the process of drug pricing and drug payment needs to become part of the clinical discussion, said Leonard Saltz, MD, Chief, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York City, at the 2017 ASCO annual meeting.
“I’m not making a judgment about whether that cost is too high or too low. I’m simply saying that to have an informed discussion, everybody needs to understand what the issues are,” said Dr Saltz.
The role of the physician is to communicate accurately with his or her patients—to provide an accurate assessment of the benefits and detriments of treatment, Dr Saltz said.
Beginning the Conversation
“Talking about toxicities may be uncomfortable, but we’ve gotten very good at explaining to people the potential downside of nausea, vomiting, neutropenia, infection, hair loss, etc. And we’re comfortable talking to people about their bowel function, bladder function, or sexual function. We ask about that as though we’re asking about the weather,” he said.
While conveying this information is an accepted part of the job, when it comes to talking about money, many physicians would rather avoid the conversation. According to Dr Saltz, however, understanding to what degree a choice in therapy will have a positive or negative impact on the financial consequences of a patient’s care is an essential part of the job.
“I would argue that we don’t have the luxury of saying, ‘I’m uncomfortable with talking about money.’ We’ve learned the hard way that we can’t protect anybody from bad news if it’s going to impact them directly in their lives,” he observed.
There was a time, Dr Saltz said, when physicians were uncomfortable telling patients they had cancer or disclosing what the negative aspects of treatment could be, but the standards of care evolve.
“That was ducking our responsibility and wasn’t really helping our patients. Financial consequences and toxicities can be part of that bad news, or it can be good news if intelligent choices are made,” he said.
Addressing Financial Toxicity in Clinical and Academic Settings
Although the discussion of cost with patients is a “primary clinical responsibility,” it should not be limited to the bedside. Rather, the financial aspects of treatment should also have a greater place in academia—in publications, in ASCO presentations, and in journal articles.
“You wouldn’t accept my talking about a new treatment for colon cancer without discussing the incidence of serious side effects,” he said, adding that cost should be considered in clinical trials, as well. “When we’re doing trials with marketed agents, we know what the cost is, so we could realistically figure that into our toxicities.”
“We wouldn’t accept a grant proposal that didn’t outline the expected costs, and we wouldn’t accept an informed consent form that tells a patient about a clinical trial that doesn’t outline what the potential side effects are, and yet we routinely say that we’re not considering what this might cost a patient or what cost this might generate,” he continued.
Financial toxicity is largely neglected in academic discussion, said Dr Saltz, although it can be easily determined, especially for drugs that are already on the market, and therefore their prices are known. The only thing that keeps providers from considering cost is historical precedent.
“Everything in medicine is above consideration of cost. That keeps us from pursuing this, but I think that is shortsighted,” he said.
Whatever standard is ultimately agreed on—whether average wholesale price, average sales price, or a price identified by the author—that should be included in the publication and be part of the discussion.
“Of course, it’s going to be very difficult for us as individual physicians and practitioners to understand what the immediate out-of-pocket expense for any patient might be, but we can certainly start with the overall cost. We can then look into computer applications or other means to let the patient understand what portion they might be responsible for, but understanding that base price is going to be important,” Dr Saltz concluded.