Prominent Oncologist Applauds First Conference of the Association of Value-Based Cancer Care
Interview with Al B. Benson, III, MD, FACP
On March 29-30, 2011, approximately 200 oncologists, payers, managed care executives, and drug manufacturers gathered in Philadelphia for the First Annual Conference of the Association for Value-Based Cancer Care. VBCC asked Dr Benson to share his thoughts on the conference and some of the issues it provoked.
Q: From your vantage point at the top of academic, clinical, and research expertise in oncology, did you find this conference of benefit? Did the meeting provide value to the variety of healthcare stakeholders attending it, including community oncologists, payers, and manufacturers?
Dr Benson: Absolutely. There is a general concern in healthcare that instead of encouraging people to work together to discuss these very serious issues in healthcare delivery, there are efforts to force people to distance themselves, particularly from industry, and work in silos, which is not in the public’s interest. We need a very transparent process that allows people to understand these various associations but also to understand that solving so many complex healthcare issues will take everybody working together.
The fact that we are having a forum with this conference, where clinicians and third-party carriers are discussing issues together, where the pharmaceutical industry and the diagnostic industry are talking with insurers, with clinicians there is hope that this type of communication has great potential for each of these critical groups in healthcare delivery to understand where each component is coming from, and understand each other’s issues, which we trust over the long-run will lead to creative solutions. To try to put people in “good guy, bad guy” categories is not productive for anyone.
If we look at the drug development side, the pharmaceutical industry clearly needs the expertise that comes from clinicians in terms of trial development, particularly regarding integration of biological principles and disease-specific expertise. We need the ongoing scientific expertise from laboratory scientists, from imaging experts, as well as from drug developers— all working together to design the very best trials.
These include the trials done through the public sector, that is, the National Cancer Institute, including the cooperative groups. Such interactions are absolutely essential, because the drugs after all are coming from industry. But for the industry trials also, we want the very best trials developed across the board. We want trials that will bring forward important human biological data to help us better select patients who are more likely to benefit from the various drugs under development. And this is going to take encouragement; an environment where people are communicating with each other.
Q: Does it also relate to payers or policymakers?
Dr Benson: Indeed. Insurance carriers, including our policymakers and government agencies, clearly need to comprehend what it takes to deliver effective oncologic care. There is the need to understand how we can offer this care to the greatest number of people— access is a critical issue—and how can we make sure that we are using the resources to the best advantage for the patient. They need to understand that we are making progress in our ability to select patients who will have the best opportunity to benefit from these therapies, although we certainly have much more work ahead of us to accomplish this goal across disease sites. At the same time, we should make it clear when an agent is not going to provide benefit for the patient.
In addition, to more effectively use imaging, we need to look at risks and benefits, to be able to decide when to order particular scans, and so on. The effective use of imaging requires strategic thinking for each patient to decide what is the intended goal, what we are going to learn from imaging, how is this imaging going to affect the care delivered, and will it result in altered decision-making. In other words we need to get people to think more carefully what tests—diagnostics and imaging alike—will truly add benefit. Some tests of course are clearly for safety, and we have to consider what will help us make sure that an intervention is being safely administered. Other issues are to look at the effectiveness of the therapy, and to look for recurrence, with the understanding that if we find recurrence, we are going to intervene in an attempt to enhance outcome.
Q: This is directly relevant to a key issue in oncology—personalized medicine. Did the conference have any relevance to this?
Dr Benson: Yes, it goes hand in hand. To effectively achieve the goal of personalized medicine, you have to have everyone in the healthcare enterprise engaged to understand and to help get us to our goal. That requires an environment that encourages innovation on the one hand, even though innovation may come at a cost.
On the other hand, if innovative strategies help us with much better patient selection, in the long-run we are at the very minimum using dollars more effectively, but we could also have huge cost-savings. Perhaps those cost-savings need to be invested in other components of healthcare, so that our overall health expenditure may not actually decrease. Given our expanding and aging population and the advances in providing care, we may end up spending the same amount but getting better outcomes from the dollars we spend.
At least we would know that we are getting value. We would project that value in healthcare delivery could have other ramifications, such as keeping more people gainfully employed, so that they are able to care for themselves and their families, as well as contribute to the overall economy.
Furthermore, expanded innovation should lead to more jobs, more industry to enhance the economy, and more development of infrastructure. There are so many permutations that we could foresee, but if we do not have everybody getting together and talking about these issues, we are not going to have the optimal solutions.
Q: Where do you see personalized medicine today, and where will it be in, say, 5 years? Are we moving in the right direction?
Dr Benson: I think we are clearly moving in the right direction, because if we look at the past 5 years, I don’t think people could have predicted the advancements that we see now. We already have more biologic factors we are able to use, at least in some circumstances, for patient selection. Our technology— the laboratory technology, the informatics technology—is all developing at a very fast rate. And these kinds of developments enable us to do a lot of the work in terms of understanding human biology.
If we just look at the tumor assessment technology, where in the past people might have only been able to do experiments with fresh tissue, now a huge amount of work can be done from tumor bank material, for example. And because there is increasing understanding of human tumor biology, we hope that in the long-run this will drive drug development. I don’t think we could have predicted the role of KRAS in colon cancer, for example. The expectation is that this process will accelerate.
With the economic concerns, however, one question is whether we will continue to recognize that investing in healthcare innovation is absolutely critical, because not only will it lead to better understanding of human disease, it should also lead to far better ways to deliver healthcare and to deliver appropriate treatments to people who will benefit from them.
Q: You mentioned value earlier, which is not an easy issue. How do you understand value in cancer? Are we talking about survival, reduced costs? Some people say that a treatment that prolongs life for 1 or 2 weeks does not really provide value.
Dr Benson: That is part of the problem when people are talking about outcomes, and why we need different paradigms for clinical trial design. Currently, when we evaluate a treatment, we have eligibility criteria, but these are still for the most part very broad.
We know that cancers, even within a given stage, are very heterogeneous. There are multiple biological pathways that are engaged in the same tumor, and we know that within a given group of patients, outcomes vary considerably. In such a situation, we know that an intervention is not going to benefit a certain percentage of patients. We are designing the trial so that we project that a certain number of patients will benefit, which will show that the drug has activity for at least some people in that group.
So when we look at the statistics, we are looking at this diverse population, and until we can truly separate those who will not benefit, and those who have a high likelihood of benefit, we are not getting the full value of the intervention.
When people make a comment such as, “well, it only extends survival for this limited period of time,” that is true in a broader collection of people who were participating in the trial; but, clearly there are some individuals who got great benefit—yet we are unable to adequately select those who would benefit and those who would not. These trials that typically have relatively unselected populations of patients can show the potential for that drug for a much better selected group of patients, and that should lead to more research to get to the point where we can identify the people who will benefit.
With cancer medicine we are often dealing with a continuum, and that is where the concept of incremental benefit comes in—if you have multiple regimens with incremental benefits for individuals, that can lead to prolongation of overall survival. Everyone would love to see a therapy that greatly improves the cure rate and greatly improves overall survival. That clearly is possible if we can better define populations of people where that may happen. But to get there, it is going to take much more profound understanding of human biology. Continuing to invest in drug development has to go hand in hand with understanding tumor biology.
In summary, the design of clinical trials will undergo a change in paradigm, where we are not just entering hundreds or even thousands of patients on a given trial, but rather on studies that are much more focused with selective populations, which will be to everyone’s advantage in terms of risk versus benefit, efficacy, and resource utilization.
People need to be speaking the same language and understand these principles. That takes all components of the healthcare enterprise to support these collaborative strategies. We hope to see much more interaction among the multiple stakeholders of the healthcare system, as has been evident at this conference.