The health economics of palliative care

Only a few studies have assessed the economic outcomes of palliative therapy. The major areas of interest include hospice care, the process and structure of care, symptom management, and palliative chemotherapy compared to best supportive care. Compared with nonhospice care, hospice care saves at best 3% of total care costs. Advance directives done early in the disease course may save end-of-life care costs, but when done in the hospital do not save money or influence care choices. Nurse coordination of palliative care maintained clinical outcomes of dying patients and saved 40% of costs. A structured ethics review of those likely to die in the intensive care unit also appears to match the type of care to the outcome, and save costs. There are remarkably few randomized clinical trials of pain and symptom control interventions in end-of-life care, so few conclusions can be drawn about current treatments. There are no examples of chemotherapy that save money compared to best supportive care. Current data suggest that changes in palliative care cost can only come from dramatic changes in how we provide care. One model is coordinated, expert, high-volume care that can prevent end-of-life hospitalization, with early use of advance directives. Preliminary data from our program support the hypothesis that costs may be reduced by 40% to 70%.     

The state of academic cancer surgery in the UK

Despite media and public perception to the contrary cancer surgery is the most important modality for the control and cure of cancer. However, after years of underinvestment by research funders and increasing service delivery demands the academic cancer surgeon is an endangered species. In an effort to improve evidence‐based policymaking in this critical domain of cancer research the ECRM has conducted a semi‐quantitative assessment of the state of academic cancer surgery in the UK. We have found that the percentage of investment in cancer surgical technologies R&D is less than 1% and even when this is extended to other diseases then this figure is still less than 1%. A decline in the overall numbers of academic surgical staff is paralleled by our finding that over 50% of the academic cancer surgeons in this survey had insufficient time for research. With clinical trials and surgical technology development identified as key research domains the majority (60–80%) did not perceive any benefit for surgical research in these areas as a result of the creation of the UK National Cancer Research Institute. We also found high support for academic surgery from colleagues but medium–low support from many institutions. Key policy conclusions are: (1) greater hypothecated investment by research funders, particularly for the development of surgical technologies as well as clinical trials, and (2) the creation of cancer surgery centres of excellence which have sufficient staffing and institutional support to engendered a creative academic environment.     

The value of innovation: the economics of targeted drugs for cancer

Oncology therapeutics have entered a new era, with the recent approval by the US Food and Drug Administration of 16 novel targeted agents. In many instances, these agents have led to breakthroughs in cancer care, such as imatinib for the treatment of chronic myeloid leukemia and bevacizumab for the treatment of colorectal, lung, and breast cancers. Toxicities of targeted agents are also novel-no longer primarily resulting in hematologic, gastrointestinal, and skin toxicities. As with all new and innovative therapies, the price tags for these agents are substantial, ranging from a mean per person annual cost of $13,000 to $100,000 in many cases. Despite the high cost of these drugs, the value of these agents has been important. In this paper, we review the concepts of value and cost effectiveness as they apply to targeted cancer agents and provide some initial insights on the economics of targeted oncology drugs.     

The status of cancer care in the Chuvash ASSR

Recent years have witnessed an improvement in cancer patient registration procedures (due to the introduction of the automated system for cancer information processing), cancer control establishment network and the level of oncological awareness of general practitioners. The need of taking fresh measures aimed at improving diagnosis of malignancies of the stomach, breast and cervix uteri which are the leading factors of morbidity and mortality in the Chuvash ASSR is discussed.     

The quality of cancer care initiative in the Netherlands

BackgroundIn 2007 the Dutch Cancer Society formed a ‘Quality of Cancer Care’ taskforce comprising medical specialists, from all disciplines involved in the care for cancer patients. This taskforce was charged with the evaluation of quality of cancer care in the Netherlands and the development of strategies for improvement.ObjectiveThe experts first focused on the relation between procedural volume and patient outcome and later aimed to identify other factors associated with high and low quality of the care provided in different regions and (types of) hospitals in the Netherlands. The question if cancer care in the Netherlands could be organized differently to assure high quality of care for all patients, was the main subject of investigation.MethodsAn extensive review of the literature on infrastructure, volume and specialization on the one hand and outcome on the other was performed. In addition, a meta-analysis of the volume–outcome relationship for pancreatectomies, bladder, lung, colorectal and breast cancer resections was performed. Finally, variation in quality of cancer care between regions, groups of hospitals and individual hospitals in our country was investigated on data from the Netherlands Cancer Registry.ResultsIn the Netherlands quality of care varies by hospital and region. These differences are not limited to surgical procedures and postoperative mortality, but are also demonstrated in other parts of the care process. Differences are only partly explained by differences in infrastructure, procedural volume and specialization between hospitals. Essential information on differences in case mix between these hospitals are lacking from the Netherlands Cancer Registry. More detailed clinical data are needed to reveal the mechanisms behind the differences in quality of care between Dutch hospitals.ConclusionOn a population level, there is potential for improvement of outcome for cancer patients in the Netherlands by reducing variation in optimal treatment rates between hospitals. Not only treatment of tumours with a low incidence but also other complex or high risk cancer procedures should be provided in a specialized setting, with the right infrastructure, sufficient volume and adequate expertise. In addition, outcomes should be monitored continuously and fed back to individual caregivers.     

Recent trends in cancer mortality in the UK

Comparisons of survival rates of given diseases with different treatments or in different places often gave misleading results until the introduction of controlled trials. Recent reports of relatively low survival rates following the treatment of cancer in the UK compared to the rates in other countries, not based on controlled trials, may consequently be misleading. Their validity has, therefore, been tested by comparing the levels and trends in mortality--the ultimate criterion by which the success or failure of any system of care can be judged. For this purpose, rates and trends in rates over 20-50 years have been compared in five European countries of similar economic status (France, Italy, the Netherlands, Sweden, and the UK). The UK rates are not generally worse than those in the other countries and are sometimes better. Exceptions were cancer of the lung, large bowel, and breast, the first of which is explained by differences in the prevalence of smoking.