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2 Opening Remarks: What Is Value in Cancer Care and Why Is It Important? This is a unique economic time in America, and health care is inter- twined with our broader economic difficulties, said Dr. Scott Ramsey of the Fred Hutchinson Cancer Research Center. Oncology spending is growing at more than 15 percent annually, faster than total health spending and much faster than total United States gross domestic product (GDP). As a result, oncology patients are feeling the pinch, and cost considerations are becom- ing increasingly intrusive concerns for patients, providers, and payors alike. Much of this spending in oncology is driven by three factors: • Less expensive treatments are being replaced with more expensive treatments with varying degrees of effectiveness. • Physicians are being more aggressive in the amount of treatment and treatment combinations given to cancer patients. • Because patients are living longer, the period of treatment is being prolonged as well. In oncology, there are certain factors that discourage consideration of evidence concerning safety, effectiveness, and cost-effectiveness. Cancer patients perceive that they are in life-threatening situations, often correctly. This creates urgency that can drive the use of technologies with less evidence for their effectiveness, and patients and physicians in this situation may discount the harms of treatments when they perceive that the only alterna- 

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 assessing and improving value in cancer care tive is usual care with a known mortality risk. Some view cost concerns as unimportant, or even inappropriate and offensive, when considering treat- ments that might improve survival. In addition, the health care delivery system’s incentives favor treatment over many other important steps, such as providing patients further information, comfort measures, or end-of-life planning, and these may take second place to costly interventions. The task set out for this workshop by the planning committee is to address issues related to value in cancer care by identifying agreement in our understanding of value and providing policy tools that can lead to improvements in the value of cancer services provided to patients, said Dr. Ramsey. It is important to discuss terminology used to describe value and the metrics used to measure it, since discussion becomes difficult without a mutual understanding of what is meant by the term value. There is no one description of value that everyone agrees on, which is why it is important to understand what constitutes value from the perspectives of many stake- holders—patients, clinicians, payors, industry, and others. We hope that a greater understanding of value from various perspectives will help us jointly weigh the costs of treatments with their risks and benefits. Many descriptions of value have been proposed previously and may be useful for understanding value in cancer care. Definitions of value in the Merriam-Webster dictionary (Value, 2009) focus largely on a return for a cost in terms of goods or services. They often focus on money, worth, and numerical quantity. This parallels themes at issue for value in ­oncology— relative worth, fair return, costs, and measures of quality. Health systems in countries worldwide have described value so that stakeholders in these countries have a common framework for discussion. The European Observatory on Health Systems and Policies (Sorenson et al., 2008) describes value as follows: “Value includes patient preferences, quality, equity, efficiency, and product acceptability among a wide range of stakeholders.” Interestingly, cost is not explicitly mentioned here. The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) states, “The value of a treatment is based on scientific value judg- ments, including clinical evaluation and an economic evaluation, and social value judgments, including considerations of efficiency and effectiveness” (Rawlins, 2004). Notice that it focuses on scientific and clinical judgments, and that economics, social judgments, efficiency, and effectiveness are also included. In the United States, Pharmaceutical Research and Manufacturers of America (PhRMA) states that “The value of new and better medicine stems not only from the improved treatment of disease but also from a

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opening remarks  reduction in other health care costs, increased productivity, and better q ­ uality of life” (PhRMA, 2006). Dr. Ramsey explained that a survey had been distributed to the ­speakers before the workshop asking them to describe value in cancer care in one sentence. The survey responses were quite varied. Dr. Ramsey presented common concepts, domains, and metrics identified by the informal speaker survey. Concepts and domains included duration and quality of life, health status, cost, equity, compassion, and opportunity. Metrics included q ­ uality-adjusted life-years (QALYs), efficiency, effectiveness, necessity, rea- sonableness, and affordability (Table 2-1). Dr. Ramsey ended his opening comments by emphasizing the variety of conceptions and metrics of value found in this survey of just the workshop’s small group of speakers. TABLE 2-1  Concepts, Domains, Metrics, and Assessments of Value Identified in an Informal Survey of Workshop Speakers Concepts and Domains Duration of life Quality of life Health Status Cost Quality of care Equity Compassion Opportunity Metrics and Assessments QALYs Cost per QALY Cost for quality Efficiency Effectiveness Necessity Reasonableness Affordability SOURCE: Ramsey presentation, February 9, 2009.

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 assessing and improving value in cancer care REFERENCES PhRMA (Pharmaceutical Research and Manufacturers of America). 2006. Value of medicines: Facts and figures 2006. Washington, DC: Pharmaceutical Research and Manufacturers of America. Rawlins, M. 2004. Scientific and social value judgements. London, UK: National Institute for Clinical Excellence. Sorenson, C., M. Drummond, and P. Kanavos. 2008. Ensuring value for money in health care: The role of health technology assessment in the European Union. Copenhagen, Denmark: The European Observatory on Health Systems and Policies. Value. 2009. Merriam-Webster online dictionary. (accessed April 28, 2009).