Bending the cost curve in cancer care.

Annual direct costs for cancer care are projected to rise — from $104 billion in 20061 to over $173 billion in 2020 and beyond.2 This increase has been driven by a dramatic rise in both the cost of therapy3 and the extent of care.4 In the United States, the sales of anticancer drugs are now second only to those of drugs for heart disease, and 70% of these sales come from products introduced in the past 10 years. Most new molecules are priced at $5,000 per month or more,5 and in many cases the cost-effectiveness ratios far exceed commonly accepted thresholds.6 This trend is not sustainable.7,8 We must find ways to reduce the costs of everyday care to allow more people and advances to be covered without bankrupting the health care system. Brody recently challenged each medical specialty to identify at least the top five tests or treatments for which costs could be substantially reduced without depriving any patient of meaningful benefit.9 Medical oncologists directly or indirectly control or influence the majority of cancer care costs, including the use and choice of drugs, the types of supportive care, the frequency of imaging, and the number and extent of hospitalizations. Here, we respond to Brody’s challenge by suggesting five changes in medical oncologists’ behavior (Table 1) and five changes in their attitudes and practice (Table 2) that will bend the cancer-cost curve downward. We recognize that these changes will cause discomfort and adjustments, since all of them will inevitably result in dissatisfaction for important constituents such as patients, physicians, or payers. Unless otherwise stated, our recommendations are restricted to the care of patients with incurable solid tumors and not those with curable cancers.