Appropriate stewardship of limited health care resources compels us to target therapies to prevent costly over utilization. The work of Silber et al. (32) was a good beginning. Development of more precise methods to target only those patients at risk for the complications of neutropenia is urgently needed. The cost of hospitalization for an episode of FN may more than offset the cost of prophylactic filgrastim or peg-filgrastim, however.
The issues are complicated by competing priorities that often ignore hidden costs. Clinicians and patients want the safest and easiest treatment, whereas payors are only concerned with cost. A cheaper drug is more cost-effective even if it requires more frequent injections and risks patient compliance. How do payors account for the hidden costs such as days missed from work or transportation costs to medical facilities for patients or their caregivers, in addition to the disruption of lives already tormented by cancer?
Progress has been made. Lyman et al. (this volume) have continued to refine cost estimates by accounting for both the direct costs, which continue to escalate, and these indirect costs. ASCO will be updating practice guidelines for the use of granulocyte growth factors based on these economic analyses and the use of potentially curative dose-dense regimens, as discussed above. Finally, by defining the ultimate risk prediction model from DNA by identification of gene expression profiles—the underlying mystery of cancer itself—we hope to define those patients who will not require granulocyte support for these toxic treatments (55,56).
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