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Nadra Septiadi, Nicolaus N. Wahjoepramono eJKI
analysis which was published online suggests that current condition, or worse; offer treatments that
many of the innovative treatments may provide are unlikely to provide any significant physiological
reasonable value for money.2 But the next question benefit to a patient, this is a failure of informed
is how to count the value within itself? Are the units choice. The act of offering the drug implies that the
we use to measure value a comprehensive model drug has more value than what it is actually worth.
able to evaluate all necessary aspects? Value- A higher price may further imply that said drug
based medicine (VBM) provides a standardized is newer, better, and more worth it. Oncologists
methodology able to integrate critical situations, should make every effort to learn what a patient
patients, quality-of-life preferences, and societal truly values in their life, as it may not necessarily
costs to allow the highest quality at the most be the same in each person. Is a longer life
cost-effective care.4 Nowadays, VBM and cost- truly worth the suffering that comes with painful
effectiveness studies are more or less empty treatments? Is a slightly longer life, together with an
gestures and have become an academic exercise increased quality of life worth the knowledge that
of no meaningful consequence. his predicament has brought debilitating financial
The value-based evaluation of any drug should instability within his family? Will it be that being
already be a given. The best way to integrate this in able to do certain things the patients goal? Or is it
cancer case is to construct a unit which incorporates staying out of the hospital? Oncologists and other
not only the treatment cost, but also the impact on health care professionals should recognize and
the patients length and quality of life. The best unit translate these values and preferences into goals
able to represent all of these is a ratio of a drugs total of care as a framework for considering the benefits
cost per patient quality-adjusted life year (QALY) and burdens of different treatment options. The only
gained, which is called cost-utility ratio. National way to achieve this is through empathy and to be
Institute for Health and Clinical Excellence (NICE) able to place the patients values and expectations
defines the QALY as a measure of a persons length together with our best efforts in bringing the highest
of life weighted by a valuation of their health-related QALY a patient can achieve, in accordance with
quality of life. By converting it to costutility ratios, evidence-based practice.
this arithmetic product will indicate the additional A compelling ethical argument to oncology
costs required to generate a year of perfect health.5 professionals that prescribing practices must
The lower cost-utility ratio (cost/QALY ratio) the evolve so that clinicians do not signal to the
more favorable it will be. Cost/QALY ratio represents manufacturers of tacit acceptance of ever-higher
more efficient way to quantify health gains from prices as a status quo.7,8 Even if clinicians cannot
treatments. It will also provide better information influence price, as professionals, oncologists
to prioritize expenditure on drugs that will result in have to discuss these issues with the patients.
the best incremental treatment benefit at a lower The use of effective, empathic communication to
incremental cost per quality-adjusted life year. talk about costs strengthens the physician-patient
To meet the EBM and VBM criteria, some relationship, facilitates negotiation, and enhance
nations have enforced relating drug manufacturing the assurance in shared decision-making around
expenditure thresholds to its cost-effectiveness. care options.
For instance, in The United Kingdom, NICE use
a value of around $55.000/QALY as a cut-off for Conclusion
allowing drugs to be available within the National By implementing the consideration of QALY
Health Services (NHS).2, 6 This means that the cost into treatment options for the patient in conjunction
of a patients drug treatment should not exceed with evidence-based therapy, oncologist can
$55.000 for a year of healthy survival. Thus, drugs provide a personalized and holistic care. This will
that do not fulfill this criteria by the NHS would only of course increase the bond of trust between the
be available to patients who can afford to pay for doctor and patient which will further boost the
them privately. The next problem is that a QALY effects of the therapy. After all, the goal of every
worth in the United States or United Kingdom is health care professional is not to blatantly prevent
obviously not the same as what a QALY is worth in death, but to ameliorate the patient condition and
Asia, especially Indonesia. facilitate what was once unbearable in becoming at
When oncologists fail to explain what a least tolerable. To cure sometimes, to treat often, to
treatment can and cannot do for a patient in the comfort always; nest ce pas?
context of the patients diagnosis, prognosis, and
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Vol. 3, No. 2, Agustus 2015 From EBM to VBP in Cancer Care
89