Strategies for Appropriate Patient-centered Care to Decrease the Nationwide Cost of Cancers in Korea.

In terms of years of life lost to premature mortality, cancer imposes the highest burden in Korea. In order to reduce the burden of cancer, the Korean government has implemented cancer control programs aiming to reduce cancer incidence, to increase survival rates, and to decrease cancer mortality. However, these programs may paradoxically increase the cost burden. For examples, a cancer screening program for early detection could bring about over-diagnosis and over-treatment, and supplying medical services in a paternalistic manner could lead to defensive medicine or futile care. As a practical measure to reduce the cost burden of cancer, appropriate cancer care should be established. Ensuring appropriateness requires patient-doctor communication to ensure that utility values are shared and that autonomous decisions are made regarding medical services. Thus, strategies for reducing the cost burden of cancer through ensuring appropriate patient-centered care include introducing value-based medicine, conducting cost-utility studies, and developing patient decision aids.

INTRODUCTION

Measurements of the diseases burden and predictions of trends form the basis for decision-making and the implementation of public health policies, thereby promoting public health in any country [1]. Worldwide, countries are feeling the pressure of the soaring burden of medical care [2]. Increasingly, more countries are using the diseases burden as an important benchmark to decide how to effectively distribute limited medical resources [3].

So far, approaches to measure the diseases burden have principally focused on using (1) conventional epidemiological indices, (2) measuring the cost burden, and (3) calculating indicators of health-related quality of life (HRQoL) [4]. Of these, with respect to HRQoL, the World Health Organization spearheaded the development of an index known as the disability-adjusted life year (DALY) and continues to conduct research on the global burden of disease [5].

In Korea, in terms of DALYs, cancer had the highest disease burden in 2002 [6]; a decade later, this changed to endocrine diseases in 2012 [7]. However, when the years of life lost to premature mortality are used as the index of disease burden, cancer remained the disease with the highest burden in 2012 [7]. This shows that our interpretation of disease burden may be affected by which indices are used; thus, the use of an alternative index such as the mortality-to-incidence ratio (MIR) has been suggested [8].

Thus, the policies developed to reduce the cancer burden can be summarized as aiming to reduce cancer incidence, to improve the cure rates in cancer patients, and to decrease cancer-related mortality [8]. However, when we assessed the changes in the cancer incidence and mortality rate, and DALYs across a decade, from 2002 to 2012, we found that in contrast to the decreasing mortality rate, the cancer incidence and DALYs increased, showing that there is a need to re-evaluate the cancer burden indices (Table 1). For instance, the national cancer screening programs that were started in order to decrease the cancer burden may paradoxically increase the cost burden of cancer by increasing cancer prevalence [11-14]. Thus, the cost burden would be considered as another index of cancer burden [13].

Table 1.

Indices of the overall cancer burden between 2002 and 2012 in Korea[1]

	2002	2012
DALY [3,5]	1525	2261
Incidence [9]	229.8	323.3
Mortality [10]	149.0	131.3

DALY, disability-adjusted life years.

DALY: per 100 000 population; Age-adjusted Incidence and mortality: per 100 000 population.

The purpose of this paper was to assess whether efforts to reduce the cancer burden are having an effect not only in terms of impacting the cancer-burden–related indices, but also in terms of reducing the cost burden of cancer. And then, we would propose strategies about how to minimize the cost of cancer by implementing adequate cancer treatments centered on the patients who are customers of medical services.

OUTCOMES OF CANCER BURDEN REDUCTION POLICIES BASED ON CANCER-RELATED STATISTICAL INDICES

Decreasing Cancer Incidence

Cancer prevention is by far the most effective approach to decrease the cancer burden [15]. Computing the attributable fractions of the risk factors [16] and, then based on these results, developing primary cancer prevention strategies to suppress risk effects should be conducted preferentially and continuously [17]. The fact that the cancer incidence in Koreans has decreased since 2012 is a promising marker, which also reflects an actual reduction in the national burden of cancer [9].

Improving Cure Rates of Cancer Treatment

Improving the cure rates of cancer treatment in those who already have cancer brings on a reduced burden of cancer. Strategies to increase the cure rate include (1) making early diagnoses and (2) providing more effective medical services.

In Korea, the first of these strategies was the National Cancer Screening Program (NCSP) established in 1999. Till 2016, the program has expanded its list of cancers screened to include the 5 major primary cancers—stomach, liver, colorectal, breast, and uterine cervical—in adults [18]. The findings that all these cancers, except breast cancer, showed a decreasing trend in incidence from 2012 to 2014 [9] and that the total cancer mortality, which had increased between 1983 and 2002, showed a decrease between 2002 and 2007 can be explained as positive outcomes of the NCSP [10]. Nonetheless, further studies containing a cost analysis of the NCSP are required to assess its outcomes more accurately.

Meanwhile, the fact that the incidence rate of breast cancer, which is included as an item in the NCSP, has consistently increased should be considered cautiously with a controversy of the over-diagnosis of the cancer screening [19,20]. Because breast cancer along with thyroid cancer, prostate cancer, and renal cancer is the representative cancer that are over-diagnosed [21,22]. Over-diagnosis in turn causes over-treatment and the abuse of medical services; thus, the result of efforts for early diagnosis could lead to an increase in the cancer burden, counterintuitively [11,23]. For these reasons, the inclusion of breast cancer in the current NCSP should be re-evaluated [24]. Whereas, only screening for cancers whose burden has been shown to be minimized through early diagnosis may lead to a net reduction in the cancer burden [10].

The second strategy is to provide more effective medical services. Recently, much work in this area has involved providing personalized medicine or precision medicine, such as individualized chemotherapy tailored to the genetic make-up of the patient’s cancer [25]. Despite the increasing cost of treating cancer with such improvements in medical technology, the cost-effectiveness of these treatments in reality is scarcely substantial enough to be of any real use for evidence-based decision-making [2,14]. In other words, since a greater emphasis is placed on the efficacy of treatment than on the economic burden, the cost burden of cancers with respect to cancer treatment is increasing [11,12].

Moreover, higher cure rates lead to higher cancer prevalence, which may increase the years lived with disability and in turn contribute to the increased cancer burden [26]. Thus, measures focused on improving cure rates can lead to absolute increases in the cost burden of all cancers, excluding cancer screening program that are known as effective.

Decreasing Cancer Mortality

Whether cancer treatment was unsuccessful or was successful but the possibility of recurrence remains, decreasing early mortality to improve survival rates in cancer patients is an important part of reducing the burden of cancer. However, by endeavoring to improve the survival rates of cancer patients, we may be promoting defensive medicine or futile death-prolonging treatments, counterintuitively.

Defensive medicine refers to non-essential medical services performed to counteract medical malpractice [27]; thus, such practices can in turn entail costly medical fees, expand the medical insurance budget, and subsequently increase the burden of cancer [12,27]. In terminal cancer patients, death-prolonging treatment may also incur unnecessary expenses to delay death [28].

SUGGESTIONS FOR CUTTING THE COST BURDEN OF CANCERS: ACHIEVING APPROPRIATE PATIENT-CENTERED CARE

We evaluated how measures, except those aimed at decreasing incidence by controlling risk factors, aimed at reducing the cancer burden by improving 3 indices—the incidence rate, cure rate, and mortality rate—may paradoxically lead to increased costs of cancer treatment and thereby increase the actual cancer burden. Conversely, given that screening for only cancers that can be effectively controlled through early diagnosis leads to real reductions in the cancer burden, a 3-way concerted effort by patients, physicians, and policy-makers should be made to control the cancer burden through the 2 indices above—the cure rate and the mortality rate [29,30].

In particular, more efficient and effective care should be needed against the apparent increment in the economic burden of cancer that reflect the escalating cost of cancer treatments. This calls for a realization of appropriateness of medical services [29]. To practically drive the appropriateness of care, Brook [29] suggested that both patients and physicians must share their values and allow for patient autonomy in decision-making.

The following milestones should be met if Brook’s recommendations are to be followed: (1) a horizontal patient-physician relationship in terms of communication; (2) closing the patient-physician values gap by using various communication tools to allow patients to understand their physicians; and (3) fostering a proactive and autonomous decision-making environment for patients to choose the kind of medical services they receive [30-33]. Employing these practices will prevent us falling into the inconsistency of increasing the cost burden of cancers through mechanisms such as defensive medicine and death-prolonging treatment while aiming to decrease the cost burden of cancers. To achieve the ideal appropriateness of care, the following operational measures for these three milestones were proposed.

Building Competency in Patient-physician Communication

Patient-physician communication is one of the most important aspects of cancer treatment [34]. Because it involves informing cancer patients of their final diagnosis as well as discussing the financial implications of having cancer with them [35]. Thus, physicians must utilize action guidelines to build a positive relationship with patients [36]. To this end, a protocol known as SPIKE$ was developed [37], so that it need to be adapted and contextualized to the Korean medical environment.

Studies have found that younger patients, female patients, and patients with higher educational levels tended to demand a greater level of patient-physician communication [34]. These finding suggests that an educational curriculum should be developed that teaches physicians ways to deal with patients from diverse socio-demographic backgrounds [38].

Physicians should communicate to patients what is set out in the clinical practice guidelines (CPGs), which are developed according to the best evidence [33]. However, CPGs are not easily applicable to real-life contexts because there may not be enough scientific evidences or due to wide variation in the medical services that individual patients expect [31,38]. Further research may be done in cases of insufficient evidence. However, when individual demands differ, the next step should be to determine patient preferences, after which physicians should be able to explain the relationships between the costs of various treatments and the benefit of their outcomes [12]. Underestimating the importance of this step leads to the widespread use of defensive medicine and unnecessary death-prolonging treatment [27,28].

Development of a Values Assessment Tool to Determine Patient Preferences

Incorporating the preferences of patients in decision-making in medicine is a way of implementing value-based medicine [31]. Patient preferences are closely linked to utility, which influences decision-making processes through an evaluation of the estimated gain and loss [39].

The time trade-off technique is the most widely used indicator for measuring the utility value in patients because it is easy for the lay individual to understand and gives reproducible results [40]. An adapted scale, based on the time-trade-off technique, must be developed for a cost-utility analysis appropriate to the Korean context to be conducted [31]. This would allow cancer patients to make choices that maximize the cost-to-utility ratio with respect to cancer treatment, leading to real reductions in the cost burden of cancers [41].

Development of a Tool That Assists Autonomous Decision-making in Patients

For cancer patients, as the consumers of medical services, to be completely autonomous in their decision making, the provider of these services, or the physicians, must provide them with sufficient explanations based on the best evidence; only then can patients make an informed choice regarding their preferred mode of treatment [38].

Patient decision aids (PDAs) are currently under development. These PDAs are expected to better inform patients of their situation, to allow them to make an objective assessment of their preferences, and to promote patient autonomy when deciding the kind of care they wish to receive [32,42]. For instance, a PDA has been developed that enables patients to critically evaluate whether they will undergo screening for prostate cancer, a cancer often associated with over-diagnosis [43]; interestingly, the application of this PDA has lowered the rate of screening by 13% [44]. As such, autonomous decisions by medical consumers using PDAs will help in the long run to reduce the wastage of medical resources through practices such as defensive medicine [45,46] and will improve the quality of public health care [38,47].

CONCLUSION

Thus, the following measures would ensure that appropriate cancer care is established: the development of guidelines that build patient-physician communication competence in physicians; a scale to measure patients’ utility value; and finally, PDAs, which encourage patient autonomy in decision-making on the basis of the best evidences and utility values. Through such measures, not only the patients’ cost burden of cancers but also that of the country as a whole can be reduced.