Rising costs are bringing the concept of value into sharper focus and challenging the oncology community with implementation of value-based cancer care. As part of the ASCO Annual Meeting Education Program, three panel sessions will highlight the issue of value in cancer care and why it is an important consideration today for oncologists and their patients.
Dr. Ravi Salgia
On June 3, Session Chair Ravi Salgia, MD, PhD, of the City of Hope Comprehensive Cancer Center, will lead a discussion about how the integration of tumor biology can directly influence value-based medicine. On June 4, Session Chair S. Yousuf Zafar, MD, MHS, of Duke Cancer Center, will be joined by colleagues discussing practical solutions to counter the financial toxicity of cancer care. On June 5, Session Chair Edward S. Kim, MD, of the Levine Cancer Center, Carolinas HealthCare System, will chair a discussion on clinical pathways and new drug approvals, and how to maximize value without compromising patient care.
Molecular insights are redefining the understanding of cancer biology and leading to a growing number of targeted therapies. Yet with improved outcomes, costs continue to grow, with targeted therapies responsible for an increasing proportion of spending to patients.
During the Education Session “Value-Based Medicine and Integration of Tumor Biology,” Dr. Salgia will lead a team discussion describing frameworks for considering the value of targeted therapies and will outline key challenges for delivering on the promise of personalized cancer care. The session will focus on practical solutions for the implementation of value-based care, including investment in biomarker development and clinical trials to improve the efficacy of targeted therapy, and the use of evidence-based clinical pathways.
“There are three elements that are easily measured and reported in clinical trials: clinical benefit, toxicity, and cost,” Dr. Salgia said. This concept is reflected in the ASCO Value Framework, published in May 2016, which assessed the value of new cancer therapies based on clinical benefit, side effects, and improvements in patient symptoms or quality of life in the context of cost.1
During his talk, “Tumor Biology, Clinical Implications, and Reasons for Value-Based Medicine,” Dr. Salgia will discuss the impact of tumor biology on treatment choices. “As we move into value-based medicine, we have to consider the heterogeneity of cancer and ultimately optimize therapy based on as much information available,” he said. “We will discuss treatment decision-making based on tumor heterogeneity.”
The session will also address how to define and provide value-based care in the wake of the “-omics” revolution—genomics, proteomics, RNAomics, etc. During his talk “Cancer Care Delivery, Cost-Effectiveness Analysis, and the Path Forward in the Era of Omics,” Gabriel Brooks, MD, MPH, of Dartmouth-Hitchcock Medical Center, will address how the -omics have led to an era of more personalized medicine. “Personalized medicine means can you take all of this information and come up with the best of therapies and the least toxicities,” Dr. Salgia said. “During our discussion, we will talk about how to define value-based medicine and how to use it to decide the best treatment for a patient.”
The panel will also discuss the merits of clinical pathways in treatment choices. “Pathways have become the tools to empower evidence-based cancer care plans,” Dr. Salgia said. “In providing value-based care, it becomes even more important to have clinical pathways that guide diagnostic and treatment strategies,” Dr. Salgia said. Toward that goal, Linda D. Bosserman, MD, FACP, of the City of Hope Comprehensive Cancer Center, will lead a presentation on “Individualized Therapies, Value-Based Care, and Pathways.”
Dr. Yousuf Zafar, credit Duke Medicine Photography
Session attendees will also learn about the models necessary to value-based medicine. “As these novel therapeutics become available, how do we take the cost-effectiveness, the financial toxicities, and the clinical toxicities that can develop and judge that against the benefits?” Dr. Salgia said. “The financial implications of the various platforms and decision analyses must be taken into account, and it must reflect patient benefit.”
Interventions to Reduce Financial Toxicity
With rising deductibles and premiums and other forms of cost sharing, more patients bear a bigger financial burden for cancer care, in many cases making that treatment unaffordable even for patients who have insurance. Dr. Zafar, whose career focuses on understanding the financial strain patients are experiencing as a result of cancer treatment, will convene a diverse panel during the Education Session “Starting the Conversation: Interventions to Reduce Financial Toxicity” to identify solutions for both immediate and long-term cancer financial toxicity.
“We all accept now that patients are facing a lot of challenges in paying for their cancer care despite having insurance,” Dr. Zafar said. “The challenge is now what do we do about it?”
The session will include representatives from many of the stakeholders involved in developing solutions. Joining Dr. Zafar will be Justin McCarthy, of Pfizer, for the industry perspective; Lee N. Newcomer, MD, from UnitedHealth Group, regarding the payer perspective on reducing patient out-of-pocket costs; Shelley Fuld Nasso, MPP, of National Coalition for Cancer Survivorship, representing the patient voice; and Leonard Saltz, MD, of Memorial Sloan Kettering, to present a clinician’s perspective.
“The focus of the session will be on changes that each stakeholder can make—not to pass the blame onto others,” Dr. Zafar said. “We will all talk about how each one of us could affect this problem from our own perspective since any substantive changes toward lowering costs must involve all the stakeholders, including the pharmaceutical industry, insurance providers (government and otherwise), oncologists, and patients,” Dr. Zafar said.
The session will specifically address how to talk to patients about the financial impact of their treatment and how to link patients to appropriate financial resources. Panel members will be asked about rising drug prices and how to control them without impacting value and innovation. “There are all of these balances and interplays among all stakeholders that have to be considered to ensure the highest-value care, and that is the goal with this panel,” Dr. Zafar said.
Dr. Edward S. Kim
Clinical pathways are tools and algorithms that help providers with patient-centered, value-based clinical decision-making. In the session “Clinical Pathways and New Drug Approvals: Maximizing Value Without Compromising Patient Care,” Dr. Kim and colleagues will discuss how to design and implement clinical pathways to achieve the best patient-centered outcomes while maximizing value, especially in the current climate of new cancer drug approvals.
“Achieving the best value becomes particularly challenging when there are numerous drug approvals, as has been the case in oncology in recent years, particularly for targeted therapies that often carry a high price,” Dr. Kim said. “It becomes more difficult for providers to choose, especially if you practice general oncology.”
Attendees will learn the purpose of pathways, how pathways intersect with delivery of care and new drugs, how medical institutions are implementing clinical pathways and deciding how new drugs are evaluated and placed on pathways (or not), and what is important from the patient perspective. “It is not meant to be a session about how expensive drugs are,” Dr. Kim said. “It’s how we evaluate new drug approvals and the process of how to implement them so that we are maximizing value to all the stakeholders.”
Dr. Kim will discuss the role of clinical pathways in integrating new drugs into practice. Joining him will be Eric S. Nadler, MD, of Baylor University Medical Center, who will present “When Expensive Marginal Drugs Should Not Be Used: How to Assess Benefit Versus Cost” and Janet Freeman-Daily, a lung cancer survivor and patient advocate who will discuss “Cost-Benefit from a Patient Perspective: Incremental Benefit is Worth It.”
“There are huge implications when a drug or process goes on a pathway,” Dr. Kim said, who designed and implemented an oncology clinical pathway (EAPathways) at Carolinas HealthCare System Levine Cancer Institute, which serves as a guiding principle and practical tool consisting of guidelines, protocols, standardized orders, and best-practice recommendations. “With all the changes occurring in oncology, more organizations are looking to implement pathways; even payers are developing pathways. Institutions are doing it. The perception of what is the ultimate value balancing optimal patient care and cost of care is really important.”
The session will address ASCO’s criteria for pathways, “Criteria for High-Quality Clinical Pathways in Oncology,” which was published in March.2
*Program information updated as of March 17. For session time and location information, please refer to the ASCO iPlanner on the Attendee Resource Center.