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Ethical dimension and economic evaluation in cancer therapy: is cooperation possible?
Editor's Note
eLetter for "Economic evaluations of medical care interventions for cancer patients"
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Antonio Jirillo, MD oncologist Istituto Oncologico Veneto, IRCCS, Padova Italy, Federica Vascon, Alessandra Bernardi
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jirillo{at}libero.it Antonio Jirillo, et al.
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We read with interest the article by Shih and Halpern on the need of an economic evaluation of Medical Care Interventions for Cancer Patients [1]. A well-designed health economic evaluation is essential in order to perform an equitable health care, appropriate therapy, and a correct use of available resources that are always scarce. We know also that oncology involves life and death decisions and many possible treatments have an amount of uncertainty. In this perspective there is an important question which emerges: should economic evaluation be integrated with ethical evaluation? Zweifel el al. [2] illustrated an initial decision to allocate more resources to health may be like “Sisyphus's work” (in Greek mythology, he forever repeats the same meaningless task of pushing a rock up a mountain, only to see it roll down again). Similarly in health care, the likely consequence of source increase is an additional number of survivors, also for few months, who will exert new demands for health care. Health care cost containment, especially in oncology, is perceived as a concrete moral issue which evokes fundamental values, such as justice, fairness, the priceless dignity of each individual patient, and the therapeutic covenant. We try to illustrate ethical instruments to face allocation of public resources in oncology [3]: Macroallocation includes the amount of resources a nation devotes to health care; mesoallocation refers to strategic choices, for instance the way a hospital budgets its spending; microallocation, instead, focuses on treatment decisions regarding particular patients. In Shih and Halpern’s report the 6 main types of economic evaluation seem to be built for macro and mesoallocation of resources. Therefore, microlevel could be an important instrument for ethics consultation, that is, a process by which trained consultants or a Hospital Ethics Committee respond to requests for help to solve ethical conflicts, issues, or questions involving patient care. An ethics consultation is advisory. Patients, family members and health care providers remain responsible for their own decisions. The ethical aspects in microlevel could influence down-up the meso and macro allocation decisions. The challenge for the future could be to improve the development of internal guidelines, shared with the Hospital Health care Management Department, in order to achieve common clinical practice. The Hospital Ethics Committee should support this activity, drafting ethical guidelines on critical aspects, for example end-of-life decisions, and coordinating multidisciplinary groups. In this way, the rationing process can become a collaborative process which could be useful to emphasize the positive dimension of rationing. References 1. Shih YC, Halpern MT. Economic evaluations of medical care interventions for cancer patients: how, why, and what does it mean? CA Cancer J Clin 2008;58:231-244. 2. Zweifel P, Steinmann L, Eugster P. The Sisyphus syndrome in health revisited. Int J Health Care Finance Econ 2005;5:127-145. 3. Bernardi A, Jirillo A, Pegoraro R, Bonavina G. Allocation of public sources in oncology: which role can ethics play? Ann Oncol 2007;18:1129-1131. |
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Ted Gansler, MD, MBA, Editor CA: A Cancer Journal for Clinicians
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ca.edoff{at}cancer.org Ted Gansler, MD, MBA
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Lead author Dr. Shih is from the Health Services Research section of The University of Texas MD Anderson Cancer Center. Only Dr. Halpern was from the Health Services Research group of the American Cancer Society; he is currently affiliated with RTI International. |
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Arumugam Manoharan Graduate School of Medicine, University of Wollongong, Australia
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Prof_Manoharan{at}uow.edu.au Arumugam Manoharan
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I read with interest and appreciation the thoughtful article by Shih and Halpern on the need for economic evaluation of medical care for cancer patients, encouraging the Oncologists and members of the cancer community “to think about cost and what it will mean to the patient” [1]. As the authors are from the Health Services Research unit of the American Cancer Society, I presume that the message is largely directed at the Oncologists in the USA. The message is even more pertinent for the many hundreds of thousands of cancer patients in developing countries, where the cost of treatment is often borne by the patients; hence the need for the physicians to tailor the treatment befitting the economic status of the patients. Medical literature seldom acknowledges their predicament, nor offers any guidelines on cheaper and more affordable treatment options. Over the last decade or so, I have been using weekly chlorambucil for longterm maintenance therapy in patients with low-grade/indolent lymphoproliferative disorders [2-4]. This approach has not been tested in large scale randomized clinical trials (RCTs) due to a lack of funding. This is not surprising, since funding for such studies nowadays come from drug companies holding a patent on one of the agents in the putative trial. The difference in cost of the drugs in the two arms of the trial is an understandable disincentive for the drug company (e.g., in patients with follicular lymphoma, the cost of two-year maintenance therapy with chlorambucil would be 250 Australian dollars; Rituximab maintenance therapy over the same period would cost 64,000 Australian dollars). As a result, cheap and affordable treatment options without rigorous assessment in RCTs are relegated to the “anecdotal” category and ignored by the advocates of evidence-based medicine. In light of the above, I wish to suggest that the leaders of cancer medicine in the USA and other developed countries make an effort to understand the plight of their colleagues in developing countries and initiate studies with a view to identify reasonable but cheap alternative therapies. Such studies are probably best undertaken in developing countries (with help from drug companies for which the leaders act as consultants or advisors), under the auspices of WHO or a charitable global organisation such as the Gates Foundation. I believe such efforts have the potential for a flow-back benefit to lower the cost of cancer treatment in the developed countries, including the USA. Arumugam Manoharan References 1. Shih YC, Halpern MT. Economic evaluations of medical care interventions for cancer patients: how, why, and what does it mean. CA Cancer J Clin 2008;58:231-244. 2. Manoharan A. Long-term remissions with weekly chlorambucil therapy in patients with intermediate-risk chronic lymphocytic leukaemia. Br J Haematol 2002;118:1193-1194. 3. Manoharan A. Long-term maintenance therapy with weekly chlorambucil in patients with symptomatic or progressive follicular lymphoma. Leuk Lymphoma 2004;45:1305-1306. 4. Manoharan A. Sustained remissions with long-term weekly chlorambucil maintenance therapy in patients with mucosa-associated lymphoid tissue lymphoma. Int J Hematol 2004;79:472-473. |
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