Value: The Next Frontier in Cancer Care

Value has become a central topic in any debate regarding cancer care in the U.S. and abroad, for a simple reason: reality has caught up with us. Costs and treatment innovations are conflicting realities that force the oncology community to adopt value-based solutions to a system in crisis [1]. Although the oncology landscape is complex, we can try to depict the cancer crisis as the clash of conflicting forces. On one side, the pace of innovation in oncology is tremendous and unprecedented: newly approved drugs abound; precision oncology and immunotherapy are gradually becoming a reality; andpatients arehaving access to an increasing number of treatment options that help them live longer with better quality of life [2–4]. On the other side, the costs to treat cancer are astronomical and continue to increase, threatening our own ability to provide cancer care and causing financial harm to patients [5–7]. The reasons for rising cancer care costs are multiple and system-specific. In the U.S., important factors include an aging population, an increasing number of cancer survivors, perverse incentives for overuse of medical resources, industry monopoly power over drug pricing, overly aggressive end-of-life care, and a fragmented health care system that lacks patient-centeredness [8–10]. Given the urgency to balance the delivery of high-quality cancer carewith costs, stakeholders aredevelopingnewmodels of care delivery and reimbursement that emphasize value [11, 12]. The implications for oncologists are clear: we have no choicebut tounderstand andembrace the concept of value;we havetoreshapeourpracticestoprioritizehigh-valuecancercare and proactively engage society in discussions about what constitutes valuable care [13, 14]. The Value in Cancer Care series is a collection of 11 opinionbased articles that jointly aim to inform practicing oncologists about the pertinent facets of the value debate. The editorial board believes that informative discussions about value need to include the views of multiple stakeholders. To this end, the contributing authors represent expert members from academia, health care payers, the biopharmaceutical industry, and physicians. The topics covered are broad and include propositions for defining andmeasuring value in cancer care, assessments of oncology drug pricing and reimbursement policies, and suggestions for changes in oncologists’ practice behaviors that promote value, including early adoption of palliative care. Given the number and variety of topics, the series format will consist of articles published in consecutive issues of the journal. Whenever possible, articles covering similar topics will appear in the same issue.We hope that the serieswill encourageoncologists to champion theefforts that will transform cancer care from a high-cost to a high-value enterprise. The definition and metrics of value in cancer care are the first topics covered by the series. Value is a multidimensional concept that is not necessarily intuitive to oncologists. Central to the definition of value is the link between the costs of cancer interventions and the final product generated by these interventions, namely, improvement in patient outcomes [15, 16]. This definition implies that a value metric needs to include costs and outcomes in a single composite measure [17, 18]. Although cost measures are relatively straightforward, what constitutes meaningful patient outcome measures deserves discussion [19]. Quality-adjusted life years (QALYs) represent the standard outcome metric used in cost-effectiveness analysis to inform coverage decisions of cancer treatments in countries like the U.K. and Canada. Schrag discusses the potential applications of QALYs and incremental cost-effectiveness ratios as metrics of patient outcomes and value in the U.S., respectively. Pertinent to this discussion are several unsettled issues: Do QALYs appropriately summarize the experience of cancer patients? If so, should U.S. policymakers consider applying an explicit willingness-to-pay threshold for cancer drugs based on the magnitude of QALY benefits at the time of coverage decisions? Can alternative outcome metrics substitute QALYs for the assessment of value in cancer care? The article by Schrag provides important insights about the complexities of measuring value and highlights the advantages and limitations of adopting QALYs as an outcome metric in the U.S. health care system. More recently, expert groups have proposed frameworks to assess the value of oncology drug regimenswith the goal of assisting oncologists andpatients tomake treatmentdecisions while explicitly accounting for drug efficacy, toxicity, and costs [12,20]. SchnipperandBastian [21]elaborateon theprocessof developing these frameworks, their applicability for health care payers andother stakeholders, and limitations such as the arbitrary aspect of assigning weighted scores to characterize drug value.