great American scientist and physician, Dr. Irving Selikof, said that
“Statistics are people with the tears wiped away.” At this year’s ASCO Annual
Meeting, we will be introduced to new ideas, discoveries that open windows of
opportunity for improving our patients’ quality and quantity of life, and
creative methods of reducing the ravages of disease. Data, statistics, facts,
and erudite discussions will inundate our week. But we must realize that all of
this new information and all the biotechnologic marvels that are displayed in
the convention hall are meaningless to the person with cancer unless we are
To paraphrase Dr. Otis Brawley, too many patients are dying, not because of a lack of research but because the research is not being applied to them. Translating research and applying compassion will save more lives, bring greater comfort to our patients, and bring greater satisfaction to our professional lives.
But how can our society pay for the scientific discoveries that may lead to cures, prolongation of life, or simply a slight delay of death? Like so many wrenching decisions being considered in the face of our nation’s debt, we need to consider economics when health care becomes too expensive and crushes other societal needs.
And how shall we pay for the new discoveries, the short- or long-term therapies, the potential cures, and the desired preventions? Should economics be further introduced into the decision-making of the care we render? If a patient and family were told that a therapy being offered has a 50% chance of prolonging life by 2 to 4 months, would the patient endure the further care? If that care were to cost the patient or his/her future estate $100,000, would that alter the decision? For patients who can afford such therapy, should society be asked to fund it, essentially funding the monies passed down to the patient’s heirs? At what point does society state that decisions impacting the economics of health care are no different than those involving the economics of other aspects of life?
Where clinical studies have proven that a therapy (medication , radiation or surgery) clearly prolongs a quality productive life , particularly in the young, society should provide the care when insurance is not adequate. However, when the treatment is limited in its ability to improve life, the patient and his/her family should consider all the implications.
I will never forget the elderly patient with widely metastatic prostate cancer who came into my office with his wife of 50 years. He had Medicare, but no other insurance. He was faced with the decision of whether to continue his depot LHRH agonist, because of the co-pay of several hundred dollars. He tearfully said that he could no longer live with the idea that the medication may prolong his life a few more months, but he believed his memory would be sullied in his wife's mind because she would have less money to live on when he was gone. I tried to dissuade him and spoke to the company for compassionate care, and it responded favorably, but the patient refused and died soon thereafter, satisfied with his decision.
Considering that a significant amount of one’s lifetime health-care expenditure occurs in the last year of life, and that there is not a limitless amount of money, personal health-care economics may need to be considered as our nation struggles with controlling the debt.
The Impatient Patient
Whether we are in research, clinical care, or both, our goals are to provide the best care for our patients. There is no reasonable method of determining whether a discovery will lead to a cure, or better and longer health for patients. So the pursuit must continue with greater energy, enthusiasm, and funding. That is critical. The public has been convinced of the primacy of science and the real value of research. Our nation has made the decision to fund biomedical research at the expense of other less valued services and industrial output. But there seems to be a limit, and the ultimate consumer, the patient, is getting impatient.
Some Americans believe that they are not getting their money's worth. Science for the sake of science may be peaking in its perceived value. Application and translation of science for the betterment of health has begun to take hold of the political (and the kitchen table) discussion. Is the country improved by funding remarkable discoveries that will have no chance of improving anyone’s health? Scientists often say that one cannot predict what small finding will lead to major changes, and that is true. But there are limits to the logic, and with limited funds and a crushing debt, one must use common sense.
Thus, we must continue advancing the discoveries, the exciting science, the exhilaration of lighting the darkness of the unknown, but we should consider risk-sharing. If projects are worthy and show the promise of translating into long-term therapies, preventions, or cures, the nation must promote them. But those who benefit—whether businesses or patients—and have the means must also be willing to cover the cost through risk-sharing, direct payment, or probate.