How to Apply Cost Effectiveness Data

The question of how to apply cost and effectiveness data to clinical practice is difficult to answer, as there is no one standard that is universally accepted. A Canadian schema has been widely accepted as one reasonable approach, but it is not used in the United States.19 Some benchmarks, and representative cost-effectiveness analyses, are listed in Table 11.5. The difficulty in developing a single accepted standard of what is explicit "healthcare rationing" lies in the varied and conflicting motives, points of view, and concerns of the three P's of the healthcare system: patients, physicians, and payers. The perspectives of each are listed in Table 11.6.

The perspective of cancer patients is different from that of well people; they are more willing to accept toxic treatments, for perceived minor benefits, than most would imagine. Generally, from studies available, these patients are willing to undergo toxic chemotherapy for a less than 10% chance of cure, 3 months of life prolongation, or greater than 10% chance of symptom relief,9-12 although there is variation among patients.16 Furthermore, there is no reason for a patient to be concerned with treatment costs until their out-of-pockets expenses become prohibitive; until they reach this limiting threshold, they may feel entitled to treatment regardless of the cost.

Physicians may find themselves trapped in the uncomfortable middle ground between their patients' desire for all possible treatment alternatives and societal, or payer, demand to limit treatment costs. For most physicians there is no

TABLE 11.4. Cost-effectiveness of representative cancer treatments.

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