Quality and cost in the palliative care of cancer

Who wants second-line, palliative chemotherapy?

This paper reports on a study designed to measure the value attached to second-line, palliative chemotherapy by people with advanced cancer, compared with the value healthy people assume they would attach if they had cancer and to assess reasons for accepting or declining treatment. Subjects comprised 92 people with cancer, 76 healthy control subjects, 60 medical oncologists, 128 clinical oncologists, 72 palliative care physicians, 58 general practitioners and 59 qualified nurses working within oncology. Using a questionnaire presenting two typical but imaginary treatment scenarios, subjects indicated whether treatment would be acceptable to them and, if so, what minimum chance and duration of benefit would make treatment worthwhile. Demographic and social data were also collected. Patients accepted a lower chance of benefit than all other groups. Although the minimum worthwhile duration of benefit was more evenly spread, patients choosing lower time values were over-represented. These results were consistent even when treatment involved greater toxicity. The conclusion drawn from this study is that people with advanced cancer are more willing to accept second-line chemotherapy with a lower chance and shorter duration of benefit than others may imagine. Health care professionals must recognize this when discussing treatment options with patients.

Costs of diagnosis, treatment, and follow up of patients with acute myeloid leukemia in the netherlands

The aim of the study was to calculate the costs in various places of acute myeloid leukemia (AML). Patients less than 65 years old, who were treated for newly diagnosed AML were included. The cost analysis distinguished between diagnosis, treatment, follow-up (maximum of 2 years), and treatment of relapse. The treatment period was divided into remission induction and consolidation treatment, harvest of bone marrow (BM) or peripheral blood stem cells, and transplantation. The costs of diagnosis amounted to $3,167 (1995 US$). Remission-induction treatments cost on average $46,387 and harvest of bone marrow or peripheral blood stem cells costs $6,491. The costs of the transplantation varied between $25,531 and $44,087. Costs of follow-up amounted to $4,167. Relapse treatment, mainly consisting of reinduction therapy, costs on average $24,338. The total average weighted costs of AML patients amounted to $104,386. Treating AML patients is very expensive, and major reductions in costs are not expected in the next future. Considering efficacy and effectiveness, it seemed that choices based on costs could be made between several consolidation techniques and between a specific consolidation technique and/or palliative treatment.

Economic evaluation alongside cancer trials: methodological and practical aspects

A recent extension of clinical evaluation is "economic evaluation", which seeks to characterise each relevant alternative health care strategy in terms of a summary measure incorporating the costs and benefits of such strategies. In an economic evaluation, separate measurements of resource volumina and resource prices on the cost side, and separate measurements of survival and quality of life effects and valuation of these outcome effects on the benefit side are required. From these effect parameters, which should be calculated for all competing strategies considered in the analysis, the relative cost-effectiveness of one strategy as against the other can be derived. The degree of generalisability of the study results determines the validity of economic evaluation in decision-making. This depends on the generalisability of the clinical findings, and in this respect the so-called "piggyback" economic evaluation, which is added to a clinical trial, has its limitations. In the field of cancer, specific attention should be given to costs and effects occurring after non-mortality endpoints, to patient and family costs and to variations in treatments between settings of care. It is argued that conventional clinical trials and economic evaluations will integrate further in the future.