President Nixon's Dilemma

Andrew Pecora, MD

Dilemma (noun). A situation that requires a choice between options that are or seem mutually exclusive. Thorndike-Barnhart Comprehensive Desk Dictionary (1962)

The current question facing patients, physicians, payers, and society is: Can we truly afford to provide each patient diagnosed with cancer comprehensive, state-of-the-art care until death? Or can we afford not to?

In 1971, President Richard M. Nixon declared war on an enemy that each year claimed the second largest number of lives in the United States: a disease called cancer. At the time, little was known about the cause and biologic mechanisms of cancer, yet there was a national consensus that more information was needed to achieve victory over this dreaded disease. Consequently, President Nixon signed into law the National Cancer Act, which gave the National Cancer Institute (NCI) privileged autonomy and funding separate from the National Institutes of Health.

As we celebrate the 40th anniversary of its signing, the National Cancer Act’s “societal benefits” remain in question, according to a comprehensive review published recently (Science. 2011;331[6024]:1539). President Nixon would be pleased to know that there is little doubt regarding the clinical benefits that have stemmed from the National Cancer Act. The incidence of cancer started dropping in 1990 and continues to do so, as do the overall mortality rates among patients with cancer. Surveillance, Epidemiology, and End Results (SEER) data confirm that age-adjusted death rates have dropped from over 200 per 100,000 pre-1971 to 178 per 100,000 in 2007. The prevalence of cancer has increased significantly as well, primarily due to the increased survivorship as a result of more effective therapies. Vincent T. DeVita, Jr, MD, former director of NCI, recently stated, “The War on Cancer did everything it was supposed to do…. Every benchmark of the mandate—better understanding of the biology, improved survival, lower incidence—was hit.”

Despite the progress made in the War on Cancer, a President has another important duty: namely, to protect the integrity of our national economy. Data published in 1965 by the Centers for Medicare & Medicaid Services showed healthcare expenditures to be 5% of gross domestic product (GDP). Since then, healthcare expenditures have outpaced growth in GDP and are rapidly approaching 20%—a growth rate considered unsustainable by everyone on both sides of the aisle.

The cost of cancer care is increasing dramatically in large part due to the fruits of the National Cancer Act. Until 1996, the standard use of 5-fluorouracil and leucovorin for metastatic colon cancer resulted in a median response rate of 12 months at a cost of $100 for 6 months of therapy. While a better understanding of the molecular basis of metastatic colon cancer has led to the development of new agents that have significantly increased patients’ median survival (now 21 months), these advances also come at a remarkable increase in cost. For example, the aggregate cost of treating metastatic colon cancer can easily exceed $150,000 for an additional year of survival, compared with 5-fluorouracil and leucovorin alone. Today, translational medicine is transforming outcomes for cancer patients. Recent drug approvals like sipuleucel-T (Provenge) for metastatic prostate cancer and ipilimumab (Yervoy) for metastatic melanoma significantly increase survival, but at a cost in excess of $100,000 for a single course of therapy.

Economists use the term “moral hazard” to describe situations where consumers insulated from risk behave differently than those who bear the full risk. We often see this behavior in healthcare when insured patients who only pay a portion of the cost of treatment (ie, copays) actually drive up the demand for more—and even more expensive—care compared to patients who have to bear the full cost of care. To combat the effects of this type of moral hazard, the current healthcare dialogue now includes discussions with patients about things such as when the appropriate time is to initiate palliative care. Such discussions are designed, in part, to avoid unnecessary expenditures. In the UK, this dialogue has been elevated to the point where governmental agencies evaluate the costeffectiveness of a given therapy to determine if it is worth the investment, and then possibly deny the therapy even if it prolongs survival.

One wonders what President Nixon would have done if he knew his actions would dramatically improve the outcomes for cancer patients, but at the same time put the nation at risk of becoming fiscally unsound and uncompetitive on a global scale, largely due to the dramatic increase of cancer care expenditures. Yogi Berra, the great philosopher and former New York Yankee, once said, “When you come to a fork in the road, take it.” We are clearly at a fork in the road. Do we limit access to lifeextending care or spend ourselves into insolvency? It is no longer President Nixon’s dilemma, it is ours.

Hopefully, the broad use of evidence-based guidelines and the continued efforts in translational medicine to find cures—and not just therapies that extend survival—will allow every cancer patient to benefit from the intent of the National Cancer Act without the risk of a moral dilemma.