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ASCO Value Framework Sparks Dialogue on Patient-centered Care

by Amanda Conschafter, blog editor

With cancer care costs poised to reach $158 billion by 2020, the American Society of Clinical Oncology wants to aid physicians and patients in evaluating care options.   ASCO’s value framework, released in June, encourages informed decision making based on three elements: a treatment’s clinical benefit, toxicity and cost. The framework document acknowledges the importance of the physician-patient relationship, though some stakeholders question whether it adequately reflects patients’ experiences and needs.

The framework comes from ASCO’s Value in Cancer Care Task Force, commissioned by the ASCO Board of Directors in 2013. The task force envisions a standardized approach whereby clinicians and patients use the framework to evaluate the merit of a new treatment relative to the standard of care. In its current draft form, the framework:

  1. Assigns therapies a net health benefit score, which incorporates both clinical benefit and toxicity
  2. Adds bonus points for treatment-free intervals or statistically significant improvements in cancer symptom reported in clinical trials
  3. Allows physicians and patients to weigh the score against a medication’s direct cost.

ASCO has solicited feedback on the draft framework. Stakeholders’ feedback and patient response have effectively raised several issues about how the framework reflects and accommodates patient experiences and preferences. For instance:

What about patient-reported outcomes? Clinical trials data inform the framework’s net health benefit score. But patient-reported outcomes, which are not included in the framework’s assessment, might provide equally valuable information for patients.

At what cost to whom? The framework provides the direct cost of medications to facilitate physician and patients’ value judgements. Yet the out-of-pocket responsibility to the patient is equally, if not more, relevant to the decision-making process.

Whose value system? Two medications may carry identical net health benefit scores but differ significantly in ways that matter to patients. As PhRMA noted, one medication may provide for a defined life expectancy while another medication may offer a reduced chance for a life expectancy twice as long. The choice between the two hinges upon patients’ own unique values.

How can scores reflect post-market data and individual nuances? Clinical trials data is critical, but it may not tell the whole story about a particular medication. Some therapies prove to be more—or less—effective after they become available to patients. Net health benefit scores may not reflect this post-market data.

Likewise, as one patient story notes, the framework does not account for individual variations in response to medications.  A medication that receives a zero score using the framework methodology may nevertheless prove to be the medication with the best results and fewest side effects for a given patient.

These issues may help to inform an improved version of ASCO’s value framework moving forward. Regardless, they remind ASCO, stakeholders and patients alike that one size doesn’t fit all in the treatment of cancer—and that the framework can only ever support, not replace, a comprehensive decision making process between the patient and physician.

ASCO has requested feedback on the framework by August 21.

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