Less can lead to more for so many things: eating smaller portions, lowering sugar consumption, and driving less in favor of walking or cycling come to mind. When it comes to healthcare utilization, doing less can also result in equal or even better outcomes. Groundbreaking research presented at this week’s ASCO meeting found that some women diagnosed with certain forms of cancer do not benefit from undergoing chemotherapy.
The American Society of Clinical Oncology (ASCO) is one of the largest medical meetings annually, and at this huge meeting these research results for the TAILORx trial were huge news with big implications for women’s emotional and physical journeys in cancer, lessening toxic and unpleasant side effects of chemo treatments, and ultimately lowering healthcare costs for both patients, medical systems, and society-at-large.
The study, Adjuvant Chemotherapy Guided by a 21-Gene Expression Assay in Breast Cancer, was published in The New England Journal of Medicine on June 3, 2018, coinciding with the researchers’ ASCO presentation of the results. The conclusion of the paper states, “Adjuvant endocrine therapy and chemoendocrine therapy had similar efficacy in women with hormone-receptor-positive, HER2-negative, axillary node-negative breast cancer who had a midrange 21-gene recurrence score.” A genetic test that costs $3,000 helps to identify women who could benefit from avoiding chemo. The test is called the Oncotype DX Breast Recurrence Score.
In plain language, Dr. Kathy Albain of Loyola, one of the thirty researchers who worked on the study, said, “The study should have a huge impact on doctors and patients. Its findings will greatly expand the number of patients who can forgo chemotherapy without compromising their outcomes. We are de-escalating toxic therapy.”
Ultimately, as much as 70% of the patients in this early-sage, hormone-receptor HER-2 negative tumor population could avoid chemotherapy. This would amount to about 60,000 women a year in the U.S.
This tough decision — to “use chemo or not to use chemo” — is among the toughest choices a doctor makes. Here, there is a new guideline for doctors to use that can offer them, “tremendous confidence and reassurance,” Dr. Harold Burstein of Dana-Farber was quoted in GenomeWeb.
Health Populi’s Hot Points: One of the earliest and most important books on the benefits of “doing less” in healthcare was Shannon Brownlee’s Overtreated, which I’ve covered here in Health Populi since the start of the blog in 2007. Brownlee, now an SVP at the Lowns Institute and Co-Founder of the Right Care Alliance, pointed out the dangers of super-sized medicine, from unnecessary radiation exposure and hospital infections to medical errors and duplication of services.
Overtreatment is too often motivated by volume-driven payment, which has been the normal reimbursement scheme in the U.S. for decades — thus, the call for “value-based” payment, aka the movement “from volume to value.”
Financial toxicity has been identified as an unwanted side effect in American healthcare, first emerging from the cancer treatment providers at Sloan-Kettering Institute, one of the organizations involved in this study. I recently wrote about financial toxicity discussing a study from IQVIA Institute on the 2017 prices for oncology drugs, with all new treatments exceeding $100,000 price tags in 2017 and a median price of about $150,000 for a year’s therapy.
The second chart illustrates patient-borne costs for early stage breast cancer. A report published in May this year by the Commonwealth Fund learned that one-half of working-age Americans would not have the money to pay an unexpected $1,000 medical bill within 30 days. Here, for early-stage breast cancer, we are looking at between just under $6,000 and over $10,000 for individual patient costs to cover out-of-pocket expenses for this Stage 1 breast cancer treatment. (The source of the data is AHRQ, from a report published by the American Cancer Society and the Cancer Action Network in October 2017).
Now that patients are paying real money to share in the financial burden of health care (especially high for cancer, but for other long-term chronic and debilitating conditions, as well), financial engagement is another factor in health engagement. This means that patients, morphing into consumers, need to better understand clinical and financial options for treatment once diagnosed, and conversations with professionals in healthcare settings – doctors’ practices, hospital admissions offices, pharmacies, and other care sites — to enable truly shared decision making. It’s not enough to open up doctors notes to patients. If patients don’t understand what the notes say, and the differential costs of treatment options, full-on health engagement remains elusive.
The ASCO story is such good news. We hope the results and conclusions of the study are quickly adopted into everyday standard medical practice in primary care and oncology practices in the community.
As a sweet sidebar to the backstory of how this research was funded, the U.S. Postal Service sold a Breast Cancer Research commemorative stamp that eventually raised over $87 million for research. This was the first so-called “semi-postage stamp” in U.S. history, first issued July 29, 1998. Some 70% of the net amount raised by sales of this stamp are allocated to the National Institutes of Health, and 30% to the Medical Research Program at the Department of Defense.
This is an example of the “it takes a village” ethos of stakeholders committed to health coming together in the community. Clinical trials are expensive to run, and the TAILORx was one of the largest research programs ever launched in the cancer field. Thanks to the U.S. Postal Service for this artful, impactful collaboration…along with the many scientists and sites involved in this major study that will benefit women and the health economy.