By way of introduction, Dr. Gore highlighted data examining the economics of kidney cancer. While estimates have ranged from 2 to 6 billion dollars annually attributable to kidney cancer costs, more recent estimates have suggested that the burden may be approximately 4.8 billion dollars annually. Notably, there is a bimodal distribution with costs concentrated early (associated with diagnosis and imaging associated) and late (associated with systemic therapy) in the disease process. As may be expected given the ongoing evolution of care, costs for patients with advanced disease are increasing dramatically. Given differences in the care provided on the basis of the extent of patients’ disease, it should not be surprising that costs are differentially attributable on the basis of disease stage: patients with stage 1 disease have costs attributable to hospital costs related to their surgical care while patients with stage 4 disease have a large burden of prescription drug-related costs.
Dr. Gore then emphasized that while kidney cancer is already expensive, it is increasingly so. In particular, these increases in costs were identified to be associated with the introduction of the routine use of immune checkpoint inhibition in advanced kidney cancer.
Both expensive, and increasingly so. Associated with intro of IO care
In addition to direct, health-care related costs, it is also worthwhile, as Dr. Gore emphasized, to consider the lost productivity related to cancer morbidity and mortality. Among urologic cancers, the general skew towards somewhat younger age in patients with kidney cancer compared to bladder or prostate cancers, it should not be surprising that there are larger losses in earnings in this population. Recent estimates suggest that there may be $3.4 billion dollars in lost lifetime earnings attributable to kidney cancer.
Considering the economics of kidney cancer, Dr. Gore emphasized that there is an increasing focus on improving the utilization of high-value care in health care generally, and in kidney cancer as well. As most will know, value depends on both quality and cost.
Specific considerations relating to value in kidney cancer can center, for example, on the use of PET-CT in advanced disease and newer surgical approaches (for example robotic rather than laparoscopic surgery).
In addition to considering direct costs which are relatively commonly captured and appreciated, there may be many other indirect costs including those attributable to missed work and travel costs.
Further, treatment changes over time (including a transition between oral and infusion therapies) may also differently affect direct patient-centered costs given the transition between Medicare Part B and Part D coverage. These costs may meaningfully impact patient outcomes as low-income patients may deal with care for cost reasons: Dr. Gore highlighted data showing that low-income subsidies decrease delays in starting systemic therapy in kidney cancer.
This leads to consideration of the well-recognized financial toxicity of treatment. In general, it is recognized that this differentially affects patients with more advanced disease, younger age, lower household income, lower education, and under-insurance (such as Medicaid). In the context of the COVID-19 pandemic, Dr. Gore highlighted recently data from the City of Hope group suggesting that COVID has exacerbated financial strains among kidney cancer patients.
Dr. Gore then drew attention to a new, NIH-funded research program aimed at assessing the effectiveness of a financial counseling intervention for patients and caregivers on financial and clinical outcomes among patients with solid organ malignancies. Considering more generally, health care reform has the potential for a much greater impact. The Affordable Care Act is the most recent and influential change in health care policy. The introduction of the ACA has been associated with decreased costs among relevant hospitals.
In addition to decreasing costs, there is the potential to yield greater value through improved outcomes through the personalization of care. Identification of effective biomarkers may allow for the introduction of effective therapies leading to better health outcomes.
Finally, Dr. Gore closed by highlighting the importance of health disparities, noting that there is an increased incidence of kidney cancer in Indian/native populations and increased mortality among black patients.
Presented by: John L. Gore, MD, MS, Professor, Department of Urology, University of Washington
Written by: Christopher J.D. Wallis, MD, Ph.D., Instructor in Urology, Vanderbilt University Medical Center, Nashville, Tennessee @WallisCJD on Twitter at the 2020 Society of Urologic Oncology Annual Meeting – December 2-5, 2020 – Washington, DC