Despite great advances in treating cancer - the five-year survival rate has improved to 68% - an estimated 1.52 million new cancer cases were diagnosed in the United States in 2010, and nearly 570,000 people were expected to die from the disease.
Costs associated with cancer also are rising, now totaling $263.8 billion in the United States, including $102.8 billion from direct medical costs, with the remainder in lost productivity through illness and premature death.
Cancer drug utilization increased 0.7% in 2009, but the spending per person grew 6.1% as newer, more expensive therapies were provided to patients. These treatment advances have made many cancers a chronic disease rather than a terminal disease.
Many cancer patients are able to work with accommodations in their schedules. For health plans covering employees and dependents, the expenses and the management of cancer presents a significant challenge in stewarding benefit costs.
In addition to treatment costs, employers have to consider adjunctive therapies, quality-of-life issues and lost time to disability in their benefit designs.
Thus, cancer requires a holistic approach to patient care. Employers need to adapt their benefits programs to address this holistically and also structure their workplaces to help employees who are cancer patients cope during treatment and recovery.
Despite millions of cases, each patient is unique and demands highly personalized care. This starts with the diagnosis of cancer and its treatment, both of which have been revolutionized by advances in genetics.
Effectiveness of treatment may depend upon the patient's genetic profile or mutations within the cancer itself. Gene tests can lead to a much more targeted approach to care and less waste.
Managed care organizations encourage doctors to follow clinical protocols driven by the latest research, including the use of genetic screening tests in selected circumstances. Resources like DNADirect.com can help advise on when such tests should be done and how to interpret and apply the results.
Managing treatment options needs to take into consideration patient characteristics (other illnesses, general state of health), tumor characteristics (type of cancer; early vs. advanced; molecular characteristics), and multidisciplinary treatment modalities (surgery, medication, radiation).
People tolerate therapy differently and cancer responds widely to the different types of treatment. Benefit programs need to balance the support for evidence-based medicine with complex, individualized patient needs.
Pharmacy benefit programs need to support patients to fill and take medications as prescribed. Taking medications incorrectly can become life-threatening. A benefit that includes access to oncology-trained pharmacists can support patient adherence to therapy and coordination of care.
If the entire pharmacy benefit is administered through a single benefit, the specialist pharmacist knows all medications that a patient receives from the cancer care team, as well as from non-oncologists. Thus they can advise doctors of any duplicate therapies or harmful drug interactions.
Cancer drugs and supportive treatments can interact with drugs used for other conditions. For example, certain antidepressants, such as Prozac, Paxil and Zoloft sometimes are used to manage hot flashes associated with the breast cancer drug tamoxifen.
However, these antidepressants can impair tamoxifen's efficacy, increasing the likelihood of breast cancer recurrence by 1.9 times.
An individualized focus on nutrition also needs to be integrated into a benefit design for cancer patients. Dietary needs change during cancer treatment and recovery, especially for patients receiving chemotherapy because it impacts digestion, absorption and the body's use of food.
When personalized nutritional resources are not available, web-based services such as TherapEaseCuisine.com can be an important resource. Nutritional status can also affect outcomes of surgery.
For example, a post-surgical mortality rate of 50% was reported in elderly patients with head and neck cancer who were malnourished, compared with 11% among the well-nourished.
With treatments that can exceed $10,000 a month, it's imperative to control waste by implementing clinically sound, evidence-based coverage rules governing care and establishing economical and clinically sound rules for diagnostics.
Supportive therapies, such as anti-emetics, growth factors, or medications that treat anemia, can necessitate duration and utilization limits to maintain safety and control costs.
How a benefit plan is structured - coinsurance with a cap on out-of pocket drug costs rather than a flat copay, or pharmacy benefit rather than the major medical benefit - can also help control cost.
The evolution of oncology care has transformed the lifestyles of many cancer patients. A job provides a sense of satisfaction to cancer patients, and the nature of treatment can allow some to continue working.
Accommodations need to be made for employees who are receiving active treatment to continue that treatment by providing work schedule adjustments and time to leave for doctors' appointments. Workplace accommodation may be needed to support recuperation from difficult treatments.
Cancer care needs to be managed from diagnosis through treatment and recovery. The cost of treating cancer makes it an important part of addressing health benefits.
Flexibility and individualization are vital in addressing the circumstances of patients. Clinicians need to be fully informed about the treatment programs to coordinate care.
Pharmacists are in an ideal position to help with the coordination of care since they are frequently engaged with patients and have the expertise about treatments and managing the side effects.
Benefit providers need to take all of these factors into account when developing coverage programs that control costs while maximizing therapy and improving the quality of life.
Milayna Subar, M.D., is the national practice leader at Medco Oncology Therapeutic Resource Center. TRC was created by Medco Health Solutions to help coordinate care, help cancer patient remain on therapy and to help mitigate the side effects of treatment. It employs 250 pharmacists, nurses and support staff to assist cancer patients with the complexities of their treatment. Milayna can be reached at 201-269-4859. Follow EBN on:
