Hidden Cost Variables in Cancer Treatment

Many times, a patient comes in simply to shop doctors/costs.  I used to be amazed when large differences were found, but the root cause may be one or more of the following:

DIAGNOSTICS:  Read up on what is absolutely necessary.

1. Was adequate staging done?  Which tests were used?  Not all tests were created equal.  There is a sensitivity & specificity profile for procedures– some can detect abnormalities better & a few pick up only those likely to be cancer. Its ideal when the test does both.
2. Immunohistochemistry.  They can tease out a specific diagnosis where simple microscopy fails & are sometimes predictive of response to a specific treatment.  Further, they may afford hints on the chances of aggressive behavior or relapse.  It may be risky not to do these tests when your doc deems them necessary.
3. Tumor Markers.  Not always helpful.  Strangely, there are many patients who request them even when told that they add no information in their disease setting.
4. FISH.  Only when needed.  These days, it’s commonly done on breast tumors that stain her2/neu +2 to predict benefit from anti-her2/neu "Herceptin" therapy. 
5. Chromosomal analysis.  There was a time when we did this routinely for lymphomas, but that was in a Center were all treatment options were available to the patients.
6. Gene arrays.  In my dreams, Oncotype-DX costs only 50 pesos to do.  As it is now, doing this test may finish off the entire treatment budget.
7. Electron Microscopy, and other rarely needed tests usually used in difficult diagnoses.

SURGERY:

1. Surgeon's Fee - Not all "cheap" surgeons are inferior.  Not all expensive ones are great.  Look into their training background, volume of cases for a specific operation, etc.   Whipple's procedures, for instance— a literal killer in the wrong hands.
2. Operating Room fee.  Oh boy, this can be a shocker. 
3. Anesthesiologist's fee. 
4. Cardiopulmonary clearance.  "C-P clearance" is needed before major surgery.  This means more tests, but you'll avoid unnecessary problems from the surgery itself.
5. Postoperative Course.  A rocky recovery phase can triple your surgery expenses. 

CHEMOTHERAPY:  Except for gynecologic malignancies, systemic chemo is handled by a medical oncologist, esp in mature cancer centers.  Where "adjuvant" or post-operative chemotherapy is known to be effective, you'd be wise to invest your resources to maximize the chances of cure.  It is more costly when the cancer comes back, in more ways than one.

1. Type of Drugs.  Protocols aren't interchangeable  There should be significant benefits to justify cost discrepancies.  Ask the medical oncologist about "cost efficacy".
2. Brand of Drugs.  Branded vs. Generics— the BFAD let them all in but there are few or no comparative trials.  Some doctors play safe & stick to brands they know inside out.
3. Dose.  Now, why are so many under-dosed, even for those tumors where dose density & intensity is known to be important?  This is not the way to go!  In the curative setting, the "better safe than sorry" approach could work against you.
4. Hospitalization.  Is out-patient chemo possible?  Most problems arise a few days after the procedure.  There are many complex multi-day protocols, though.
5. Supportive Management. "The good news= no more vomiting.  The bad news= anti-vomiting meds can cost as much as the chemo."  "Less chance of infection & added convenience with Neulasta"… yeah, at only US$4000 per dose.  Ask about options– before shifting to  "Alternative Therapy"!
6. Side Effects.  When serious side effects set in, you've blown the budget.  Look up "Febrile Neutropenia" & "Acute Renal Failure", for instance. If your oncologist is also an internist, then he/she can anticipate, minimize, then treat these conditions.
7. Professional Fee.  Again, not all "cheap" med oncos are inferior, and not all expensive ones are better.  Fees may reflect a doctor's upbringing, ethics, & needs– rather than ability.

RADIOTHERAPY (RT):

1. Machine.  Most definitely, radiotherapy machines have their differences.  Ask what this means to you in terms of efficacy, side effects, and costs.
2. Professional Fee.  Ask about the "per diem", exclusive of what's directly paid to the facility for the machine's use.
3. Dose.  How many cancer treatments?
4. Type.  For example, for Gamma knife & X-knife radiosurgery (which is radiotherapy!), ask– "Is there a significant difference in aspects other than costs?"  The answer may surprise you.  Ask the same for brachytherapy vs external beam RT for prostate cancer.  Unlike IMRT for cancers of the head & neck, not all fancy options imply paradigm-shifting advantages.
5. Supportive management.  Depending upon the type and target location of your radiotherapy, you may benefit from protectants (expensive!), feeding tubes, etc.

In the Philippines, (I’m told), just tell them what to do.  Stop confusing them with information and options!  But… therein lies a problem that only an informed patient can minimize.