How should we define value in cancer care?

INTRODUCTION One of the most enduring and controversial topics in medicine is the concept of what constitutes value in health care. Certainly, one element at the heart of our national debate about health care spending is disagreement about where we are currently wasting resources (paying for goods and services that offer little value) and where we should be increasing our resource commitments (high-value goods and services that patients underutilize). Nowhere is this issue more contentious than in the care of cancer patients. Spending for oncology services is increasing by 15% annually, faster than the overall rate of increase in total health care spending and much faster than the gross domestic product. Despite this influx of resources, the death rate from the most common cancers has declined only modestly over the past several decades, much more slowly than that for cardiovascular disease, the major killer in western societies. The rapid escalation in costs of treating cancer, combined with modest survival gains, suggests that we may be facing a “value crisis” in oncology. The purpose of this paper is to construct a definition of value in cancer care and to argue for the application of that definition in our evaluation of care for cancer patients. Before addressing these topics, it is important to understand the many definitions that are possible for “value,” and how those definitions may vary depending on one’s perspective. Next, we argue that, if we are to improve outcomes and reduce what currently is unsustainable growth in expenditures for cancer patients, we must arrive at a common definition of value: a social construct for the term that can be used to make decisions about increasing and decreasing access to goods and services for cancer patients that provide high or low value, respectively. Finally, we describe a number of metrics that are currently used to measure value, the domains these metrics consider, and recommendations for metrics that are most suitable to a common definition of value that can be applied at the bedside.