Evidence Based Medicine and the Cost of Cancer Care

ASCO logoBefore 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.

About Dr. Robert A. Nagourney
Dr. Nagourney received his undergraduate degree in chemistry from Boston University and his doctor of medicine at McGill University in Montreal, where he was a University Scholar. After a residency in internal medicine at the University of California, Irvine, he went on to complete fellowship training in medical oncology at Georgetown University, as well as in hematology at the Scripps Institute in La Jolla. During his fellowship at Georgetown University, Dr. Nagourney confronted aggressive malignancies for which the standard therapies remained mostly ineffective. No matter what he did, all of his patients died. While he found this “standard of care” to be unacceptable, it inspired him to return to the laboratory where he eventually developed “personalized cancer therapy.” In 1986, Dr. Nagourney, along with colleague Larry Weisenthal, MD, PhD, received a Phase I grant from a federally funded program and launched Oncotech, Inc. They began conducting experiments to prove that human tumors resistant to chemotherapeutics could be re-sensitized by pre-incubation with calcium channel blockers, glutathione depletors and protein kinase C inhibitors. The original research was a success. Oncotech grew with financial backing from investors who ultimately changed the direction of the company’s research. The changes proved untenable to Dr. Nagourney and in 1991, he left the company he co-founded. He then returned to the laboratory, and developed the Ex-vivo Analysis - Programmed Cell Death ® (EVA-PCD) test to identify the treatments that would induce programmed cell death, or “apoptosis.” He soon took a position as Director of Experimental Therapeutics at the Cancer Institute of Long Beach Memorial Medical Center. His primary research project during this time was chronic lymphocytic leukemia. He remained in this position until the basic research program funding was cut, at which time he founded Rational Therapeutics in 1995. It is here where the EVA-PCD test is used to identity the drug, combinations of drugs or targeted therapies that will kill a patient's tumor - thus providing patients with truly personalized cancer treatment plans. With the desire to change how cancer care is delivered, he became Medical Director of the Todd Cancer Institute at Long Beach Memorial in 2003. In 2008, he returned to Rational Therapeutics full time to rededicate his time and expertise to expand the research opportunities available through the laboratory. He is a frequently invited lecturer for numerous professional organizations and universities, and has served as a reviewer and on the editorial boards of several journals including Clinical Cancer Research, British Journal of Cancer, Gynecologic Oncology, Cancer Research and the Journal of Medicinal Food.

3 Responses to Evidence Based Medicine and the Cost of Cancer Care

  1. Gary Brutsch says:

    The line in the health care cost sand has been Struck Resistance to this cost based patient care Philosophy is now at its strongest resistance Cycle In several years this philosophy will be the norm

    Sent from my iPhone

  2. gpawelski says:

    I can understand some medical oncologists not understanding the scientific method of assay validation and clinical evaluation, based on using real-time, real patient data, under real-world conditions, to guide medical evidence. In short, it is a complex and thorough analysis. Not many of them understand it.

  3. hphblog1 says:

    Reblogged this on Hope Practiced Here and commented:
    Dr. Nagourney attended the ASCO meeting in Chicago this month. His thoughts…..

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