ASCO Connection

July 2017

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Physicians frequently talk to patients about intimate and personal details of their lives. Physicians routinely ask about bowel function, bladder func- tion, sexual function, anxiety, depres- sion, alcohol and illicit drug use, and other intimate and personal details that would be far outside normal social discourse. Within this context, there is a startling inconsistency with any con- versational taboo regarding costs. Yet, discussion of the prices of treatments has been a taboo in our doctor-patient relationships, and that requires re- evaluation. Bringing the realistic costs to bear in discussions would make the most involved members of society appropriately informed of the magni- tude of the challenges faced in paying for drugs at the current prices. It would also facilitate rational discussions of efforts to use more cost-efficient regimens, use less expensive alterna- tives, or perhaps forego extremely expensive and toxic options that have little chance to provide meaningful benefit. There are very few things in life that people buy without an aware- ness of the purchase price. Such an awareness helps people make informed decisions about what goods or services they do or do not wish to purchase and can encourage people to make informed decisions about the consider- ation of alternatives. From an academic perspective, dis- cussion of price is warranted both in clinical trial design and in publications. When a trial is designed that increases the length of treatment or increases the dose of a drug to higher than the standard dose, physicians must know and consider what the costs of those changes will be. When a report is pub- lished about a regimen for which the prices of the drugs are known, those prices constitute a nontrivial toxicity to which patients will be exposed. The purpose of academic papers about therapeutic options, and the purpose of open and complete discussions between patients and providers, is to maximize the awareness of the true risks, benefits, and alternatives of the treatment strategy under consider- ation. It would be wrong to exclude consideration of physical toxicities. It is equally counterproductive to exclude consideration of price, or financial toxicity. The inability to provide full awareness of either of these likely will increase, rather than decrease, the prevalence of and the harm done by these toxicities. " It is essential that providers create a welcoming and open environment for patients to express their concerns. Providers should recognize how difficult it is for patients to raise the topic and should open the door to the conversation by asking a question as simple as 'Do you have concerns about the cost of your treatment?'" —Ms. Shelley Fuld Nasso FEATURES l Current Controversies in Oncology 26 I 07.2017

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