Reducing Costs by Holding Back on Chemotherapy for Cancer Patients Who are Frail

This is the fourth in a series of posts on Bending the Cost Curve in Cancer Care, by Drs. Thomas J. Smith and Bruce E. Hillner, in a recent NEJM health policy piece. The authors’ third suggestion: to limit chemotherapy to patients with good performance status, with an exception for highly responsive disease, is surely one of the most controversial.

What they’re suggesting is a simple rule: “Patients must be well enough to walk unaided into the clinic to receive chemotherapy.” There are necessary exceptions, they point out, such as cancer patients disabled by another medical condition but who otherwise can carry out daily activities with relative normalcy. (I’ll offer an example: say a 50-year woman with multiple sclerosis who is wheel-chair bound but otherwise essentially well; she would be a candidate for treatment in this scenario.) But in general the authors would hold off on chemotherapy for cancer patients with a limited performance status  – a measure that oncologists use to assess how well, or disabled, a person is in their capacity to work, perform ordinary daily activities and care for him or herself.

I’m not sure I agree with the “walking” threshold, or ECOG performance status 3 or below, as the authors describe: “meaning that they are capable of only limited self-care and are confined to a bed or chair more than 50% of waking hours.” These criteria are subjective and problematic. But I do think the authors are onto a central, unavoidable issue in reducing health care costs. That is by limiting care, i.e. by rationing.

For elderly patients with cancer, especially for those who have significant other illnesses, it may not be appropriate for doctors to give chemotherapy and other, non-palliative cancer treatments. The authors don’t (dare) advise a particular age cut-off for therapy; they suggest using performance status criteria. They conclude this section of the paper on cutting cancer care costs with this statement:  “Implementation of such a simple threshold could dramatically decrease the use of chemotherapy at the end of life.”

The authors are right, that we (oncologists and other doctors) shouldn’t be in the business of routinely giving aggressive treatments to patients who are very old and frail, who are more likely to suffer harms of treatment than potential benefits. Not just because we can’t continue driving up U.S. health care costs indiscriminately, but because when very frail, elderly patients are given chemotherapy they’re less likely to recover after treatment. By not saying “no” to patients who are too fragile for a requested intervention, or by simply treating patients who are so feeble or demented, or both, that they’re unable to say “no” for themselves – such as sometimes happens in nursing homes and other chronic care facilities, doctors may cause more harm than good.

Some readers of this blog may be wondering how I can reconcile this position with what I’ve said about access to Avastin for women with advanced BC. In my opinion, patients’ age and, broadly, their functionality – if they can think and communicate seems at least as relevant as whether they can walk – should be factored into the risk/potential benefits analysis of almost any medical treatment.

So if we’re going to consider restricting cancer drugs and interventions based on cost, indirectly or overtly, we should account for patients’ ages, the potential length and quality of life to be gained: If there’s a 50 year old patient who might benefit from a costly cancer treatment, it’s likely that person will benefit more from that drug than would a 70 year old patient, or a 90 year old patient. It’s also more likely, but not a sure thing, that a younger, otherwise healthier patient will tolerate a given treatment with fewer side effects.

Hard to know where and how to draw the lines.

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  • Interesting article Elaine. From a completely unscientific standpoint, I have this seen this issue with my own eyes played out in the oncology clinic that I attend. I routinely watch extremely frail patients in their 80’s and 90’s receiving chemotherapy, and with all honesty I too find it troubling, and often ask myself “why?”. You make a good point in that if the patient is of sound mind and is able to make the decision then perhaps that’s an appropriate barometer, but I also have to wonder, how many of these decision are in fact the result of pressure from families who are not yet ready to say goodbye to their loved one?

  • Thanks,
    You raise an important point about families. Med-school Ethics 101 would teach any doctor that it’s up to the patient to decide if and how much treatment they get; so long as the patient has capacity to make decisions, it’s not up to the family. But this gets complicated in reality: some patients are prodded by their loved ones to take treatment. And whether someone has “capacity” is a subjective call, especially for some older people with dementia.

  • Elaine –

    I routinely saw my sister’s docs talk about performance status with her in making decisions about chemotherapy. In general, they seemed to want her to be fairly functioning before subjecting her to chemo again, given how difficult her therapy had been. In the end, she had very little chemo – which, I think was the right choice.

    What I’m saying is that I think docs are already using performance status to limit chemo use. Yes, it lowers costs, but ultimately it is about maintaining whatever quality of life still exists rather than destroying what is left with treatment that may not be effective in the long run.

    Every patient is a balancing act, and individual choice. We err, I believe, when we use a one size fits all approach to cancer treatment – either to cure or to save money.

  • Peggy,
    I was sorry when I learned about your sister. But it sounds like she was well-informed, and got top-notch care by doctors who think.

    My impression is that many oncologists don’t adhere to this criterion, which is why it was published as a suggestion to reduce cancer care costs.

  • This is a very interesting article. Working in the publicly funded Canadian system, the cost of healthcare and the allocation of scarce resources are things that I think about often. Unfortunately, there seems to be a taboo against suggesting that treatments should be limited based on their costs, and the public seems to be always demanding that the government reach deeper into its pockets to fund full treatment for everyone. I’m glad to see someone publicly addressing the issue of cost and at least starting what I think is an essential discussion. Thanks!

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