| Abstract: |
BOOK REVIEW Kevin B. Knopf, JNCI, 1999, 91(14), 1248-1249
The need for accurate economic analysis to guide health care delivery is irrefutable, since health care costs continue to rise in parallel with a growing demand in value for our spending. Cancer care accounts for 5%-10% of all health care dollars spent in the United States, and although breakthroughs in cancer research will provide much needed improvements in the treatment of cancer, they will also come at a cost. Dr. Neymark speaks in his preface of the "aura of sanctity" surrounding cancer so that "everything possible" is done for the patients. This aura derives partly from the seriousness of the disease and the fear surrounding a diagnosis of cancer. However, a need for high-quality economic research in cancer care is still necessary to guide rational resource allocation, and this text succeeds in succinctly and thoughtfully summarizing the state of the art of economic analysis of cancer therapies. By exploring the literature related to economic evaluation of cancer therapies over a 10-year period, Dr. Neymark has provided a great deal of food for thought for research in this area.
The general nature of economic evaluation is defined in the introduction:
"Economic evaluation is a widely applicable economic method concerned with the comparison of two or more alternatives with respect to both their positive and negative impacts or benefits and costs, respectively, as these impacts are generally termed. It is the presence of alternative methods of treatments that create an economic problem."
It is the presence of choices that makes economic evaluation a valuable tool. In the past, the treatment of cancer, particularly metastatic disease, was limited in the number of options available, as the author notes. However, new treatments are continually being developed, which come with a cost versus benefit trade-off, and thus economic evaluations will assume a greater importance as our therapeutic choices increase.
The very brief chapter on the epidemiology of cancer could have been made more substantial, and the addition of graphs to interpret trends would have been useful. The following chapter provides an excellent overview of the nature of cancer and its major treatment modalities, which will be of interest to the nonclinician.
The chapters on economic evaluation and the economic burden of cancer are well written and serve as solid introductions for the novice to these areas and a good review for others. He describes the rationale and methods behind the cost-of-illness studies, which he treats with a healthy skepticism. A lengthy section on economic evaluation covers important concepts and describes, in turn, the four major types of studies: cost-minimization, cost-benefit, cost-effectiveness, and cost-utility, the latter two being the most appropriate type of study for most cancer therapeutics. Discussion about methodology involved in collecting data for cost and outcomes, perspective of the analysis, valuation, and presentation and interpretation of results of economic evaluations are also well written.
The heart of the text is a thorough discussion of the major economic studies of cancer treatment published from 1985 to 1996. The author reviews the relevant literature pertaining to costs and treatment of most of the major malignancies, including relevant supportive care areas. Topics covered include the following: breast cancer (14 studies), lung cancers (eight studies), colorectal cancer (eight studies), prostate cancer (10 studies), genitourinary and gynecologic malignancies (11 studies), leukemias and lymphomas (10 studies), therapies for emesis and infections (nine studies), hematologic support and transplantation (18 studies), and palliative care (five studies). Every section is preceded by an overview of treatment options that are fairly accurate—although not without occasional omissions and errors; these sections will be invaluable for the nonclinician.
Each study is described concisely, including rationale, type of analysis, perspective, techniques, data sources, and results, when stated by the original authors. Dr. Neymark justly criticizes studies with conceptual or methodologic flaws, erroneous assumptions, or clear oversights in the evaluation, and as a critical reviewer, he certainly holds no punches. This lengthy and in-depth review of a body of work makes his text a compelling read and enables the reader to gain a great deal of insight into how to, and often how not to, evaluate the economics of cancer therapeutics. Through reading his summation of the body of literature, one obtains an appreciation of not only what studies have been performed and which studies should be performed but also a sense of the "state of the art of the methodology" currently in use. Each chapter closes with a concise table of the articles reviewed and concluding comments that highlight the strengths and weaknesses in the studies, comparing studies when appropriate, and pointing out possible future directions.
A concluding chapter discusses some of the broader controversies, which have been hinted at throughout the review, in an insightful manner. The use of "league tables" to compare cost-effectiveness ratios is justly criticized, due to the implicit assumption of comparability of studies. The issue of costs versus charges is briefly discussed, and a lengthy discussion of the merits of collecting economic data in clinical trials points to the complementary benefit of modeling. The nature of outcomes used, e.g., the inapplicability of life-years saved as an outcome to evaluate antiemetic therapies, is also explored.
By design, this review cannot serve as a complete "how to" guide for economic evaluations, although there are many pearls to be gained from a thorough reading. The economics of cancer prevention and screening, which are in many ways more difficult to study from an economic perspective, were not explored in this text, but there are other sources for this information.
Many of the reviewed studies are excellent and may serve as an aide to treatment choices for a specific situation. In a broader sense, this book will be extremely valuable for both the health service researcher who wishes to learn about cancer economics and the cancer researcher interested in the economic aspects of their field. By reviewing 9 years of the literature in a systematic, thoughtful, and critical manner, there is much to be gained for the interested reader who invests a small amount of time reading this excellent work. |
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