US and Canadian medical oncologists share similar attitudes on the costs, cost-effectiveness, and health policies concerning new cancer drugs, despite fundamental differences between the 2 countries regarding how these drugs are covered and paid for under their respective healthcare systems. These findings, reported in the Journal of Clinical Oncology (2010;28:4149-4153), emphasize the need for greater education of oncologists on understanding and communicating cost-effectiveness and cost information with patients.
The authors surveyed a random sample of US oncologists who were members of the American Society of Clinical Oncology in the summer of 2008; the Canadian sample (n = 356) was drawn from the membership list of the Canadian Association of Medical Oncologists and other directories. The Canadian survey was not translated into French, so responses from Quebec were not included in the analysis because of the low response rate from that province.
The overall response rate to the survey was 59%. Respondents were experienced clinicians, with a mean of 23.8 years of practice in the US and 23.2 years in Canada. Responses on cancer drug costs and cost effectiveness brought both concordance and divergence among the 2 nations’ doctors. When asked if patient out-of-pocket drug costs currently influence decisions regarding which cancer treatments to recommend for patients, 84% of US and 80% of Canadian physicians strongly or somewhat agreed. A much lower percentage in both countries felt well prepared to interpret and use costeffectiveness information in treatment decisions (42% US, 49% Canada).
Opinions differed when questions turned to patient access to care. Sixtyseven percent of US oncologists indicated that every US/Canadian patient should have access to effective cancer treatments regardless of their cost, whereas only 52% of Canadian oncologists felt this way. Further refining the question to elucidate whether every US/Canadian patient should have access to effective cancer treatments only if the treatments provide “good value for money” or are cost-effective, 58% of US oncologists strongly or somewhat agreed, compared with 75% of Canadian doctors. Fewer than half of physicians in both countries discussed the costs of cancer treatments with patients.
In terms of health policies related to cancer drug costs, high numbers of doctors in both countries favored greater use of cost-effectiveness data in coverage and payment decisions (80% strongly or somewhat agreeing in the US, 69% in Canada), as well as more government research on the comparative effectiveness of cancer drugs (79% US, 85% Canada). Fifty-seven percent of US oncologists favored price controls for cancer drugs in the Medicare program, and doctors in both countries were less enthusiastic about increased patient cost-sharing for these drugs (29% US, 41% Canada). In both countries, doctors and nonprofit organizations were deemed most capable of determining whether a drug provides good value, while insurance companies and government agencies were seen as least effective in this regard.
How to Address this Growing Problem The findings are not all that surprising, say the authors, given the changes in the oncology landscape in both countries. Despite government-funded healthcare in Canada, patients there are being exposed to higher out-of-pocket costs. And the reluctance of physicians to discuss costs has been well documented in other studies.
What may be surprising is that Canadian physicians are already familiar with cost-effectiveness by its use in the Canadian system, but they still express uncertainty over actually using this information in practice. The solution may be “better coordination among international researchers interested in the use of comparative effectiveness and cost-effectiveness data in funding expensive cancer drugs,” say the authors, which “might allow for better design of future prospective studies that could yield useful information for all countries involved.”
Even more unexpected to the authors is the desire of US oncologists for greater use of cost-effectiveness data in coverage and payment decisions for cancer drugs. Although the American Recovery and Reinvestment Act of 2009 forbade using comparative effectiveness for coverage determinations under Medicare, the sentiments expressed in the survey “may reflect that US oncologists are beginning to come to terms with the unavoidable reality of resource constraints and may suggest some willingness on their part to accept comparative cost-effectiveness data in drug coverage decisions as is already happening in Canada and other countries,” the authors say.
The authors caution that the physicians surveyed may not be a representative sample, but argue that the concordance of attitudes from the 2 countries suggest the findings could have wide relevance. Greater USCanadian collaboration regarding improved communication with patients about costs, practical education on using cost-effectiveness information, and the optimal processes for incorporating cost-effectiveness information in drug funding and coverage decisions could help address this widespread problem
