The Business of Cancer Care: Candid Conversation with Dr Derek Raghavan

John Marshall, MD: Hey, everybody out there in Internetville, or maybe you've got us on your earbuds while you're going for a walk. You should go for a walk. It's good for your soul.

John Marshall for Oncology Unscripted, and I am so excited to have with me today Dr Derek Raghavan. I have known Dr Raghavan a long time now. We are both old. He's maybe a bit older than I am, but he's got a lot more to show for it. We've known each other on committees. He has helped organize many a cancer center and its relationship to the community. He's, of course, an advisor, a major player in ASCO, in our cancer community, and a real leader in research. And he was nice enough when I asked him if he'd join on Oncology Unscripted to pretty much right away say yes.

So Derek, welcome, and welcome to Oncology Unscripted.

Derek Raghavan, MD, PhD: John, we've been friends for a very long time. It's great to have a chance to see you again. It's been a while.

John Marshall, MD: It has been a while, and this is not the best way to catch up, but I will take it, I promise.

But the reason I thought of you, and I shared this with you right before we went on, is that this came in the mail. I still get paper. I don't know if you still get paper, but I can't really find stuff online very well. So I got the paper version of the current JOP, Journal of Oncology Practice, and I started scanning down, and every one of the articles had something to do with the business of oncology. Then I actually recognized that the whole edition is about the business of oncology.

Then I found the summary, and that is written by you. And you basically titled it, "Epilogue: Cancer Care in the United States—Jekyll and Hyde." And I immediately flipped to the back, read the whole thing, and thought how impactful this was. And maybe just to open us up a little bit, how did the idea for making this come forward, and what sort of bubbled this up?

Derek Raghavan, MD, PhD: Well, the group who edits, I'll abbreviate it that way, is led by Jeff Peppercorn, who's a very thoughtful guy in the Harvard Teaching Hospital system. What's terrific is he is not a top-down editor. He sort of encourages people to come up with ideas, and so we have pretty good free flow of ideas.

The idea for this actually came from John Burke from US Oncology and Blase Polite from the University of Chicago. And they're 2 very thoughtful oncologists, one more practice-based, one more academically based. And in one of our editorial board discussions, they said, "You know, there's a lot happening in the business of oncology that people don't understand, a lot of decision-making processes that go on. Why don't we put something together?" And then they spitballed people that might be involved, and I was certainly not on that list.

As you and I have known each other for a long time, I am known to be opinionated and express them without too much abdominal pain. So Blase said to me, "You know, it'd be really good if you could sort of do an overview of the whole volume, and particularly so before you've actually read the other papers." I said, "Okay, I'll give it a shot." And then I subsequently did read the other papers, and it all sort of came together fairly well.

We thought it would be useful because there are so many adverse influences in health care today. I personally think they've come largely since the time of COVID-19, which set doctors and nurses in counterpoint with some aspects of the patient community, and it's gotten worse since then. And part of it is just predicated on misunderstanding how stuff works in health care. So I thought it would be fun to be involved in this.

We've gotten a lot of people responding to the various articles that have been written. And I think John and Blase sort of asked people to cover the topic as dispassionately as possible, try to give objective assessments of whatever they were writing about. I think by and large, people did a pretty good job of trying to be honest. That's one of the big challenges today: having honesty in health care.

John Marshall, MD: Well, and what is truth? I mean, given the world today, if you guys out there listening haven't gotten this and read through it, it really is totally worth a read. Those of us who are in this business and influence this business, this is, as you put, I think a really honest, sort of truthful, analysis of what today's world looks like, our positives from this, but also where we are at risk and the negatives that are out there as well.

Were you all thinking about either personal or corporate risk-reward as you wrote this? Did you have some idea that this could influence how we do things going forward? Kind of a position paper?

Derek Raghavan, MD, PhD: My view was, you know, I'm Australian originally, and America has treated me very, very well. I would like to see us more successful than ever. It sounds kind of corny, but I kind of believed in Ron Reagan's sort of shining light on the hill, although I'm not politically influenced one way or the other. But I kind of like that concept of America being the shining star, and I think the luster of the star has slipped a little politically, certainly, and maybe in health care recently.

One of the things that's always kind of influenced me in the latter part of my career. You know, John, I was at the Cleveland Clinic for a long time. They were smart enough, Toby Cosgrove, the CEO, was smart enough to get a fellow called Mike Porter to come and lecture the department and division chiefs about health care and value and stuff like that. And everything he said made sense to me. It struck me that we don't think about what the patient is getting for whatever expenditure of time or personal, financial expense or physical expense. What are they getting back? So thinking about value has been something that's been top of mind when I designed the Levine Cancer Institute here in Charlotte.

So, for me personally, writing this was to say, "Hey, guys, let's think a little bit more about what we're doing with dollars that we expend in health care. Do patients understand what they're getting? Can we help them make good decisions?"

You know, one of the things that seems to me, you know, we developed a thing, and we can talk about it if you wish, the Financial Toxicity Tumor Conference. One of the things that strikes me is we say, "Oh, yeah, I've got health insurance." If you have health insurance with a copayment of, say, 10%, you get a bill for half a million dollars, and there are some drugs that have just come available in pancreatic cancer, you and I were talking offline, that'll cost pretty close to half a million dollars a year. There are a lot of people in America who can snap their fingers and say, "Oh, yeah, I want to spend 50 grand on health care as out-of-pocket costs." So my thinking about writing this thing was to say, "Is this maybe fixable?"

The way I kind of see it is, you know, I've practiced in Australia and in Britain, they both have nationalized health systems. The one kind of, it's almost a joke, funny thing that I always say is, in America it's sort of like death is an un-American activity. In Australia and Britain they accept it a little bit more, and the truth should somewhere be in the middle, I guess. So we sometimes do things that aren't actually prolonging life or quality of life, cost a lot of money, cost the patient a lot of money, and have side effects.

So my piece here was to say, could we do it cheaper? Drugs in the US that might cost X dollars might, in India, for example, cost 0.01 X dollars. Why would that be? And so one of the points I was making in my paper was maybe we should have government thinking a little bit more about that. Now, I do know the current president has spoken about that and has actually executed a couple of things to bring costs down. The trap when politicians do that is to ensure that they're not protecting their buddies at the expense of people who aren't their buddies. So these sort of issues are very complex amalgams of a lot of different conflicting forces.

John Marshall, MD: You know, I think about the current administration and their emphasis on free market, whatever that means. And I think about, I always put the flag in the ground at when Bush II put in the Medicare Expansion of Drug Access Act, where along with that went this inability to negotiate prices of new medicines. And nowhere have we seen this have more of an impact than sort of our fancy diseases, cancer and neurosciences and others, where you now have ads during Jeopardy because they cost as much as a new Toyota Camry per month. And so, even if I can sell one, it's worth the ad on Jeopardy. So that's escalated. Therefore, no free market.

We also have health care systems that sort of bill what they can get away with. And then we, I think, on some level it's because where the money is coming from, we're removed from that. It comes from the payer. I have health insurance, I have Medicare, and they're the guardians of the bank. The way I like to think about it is that they're the guardians of what we pay them every month, whether it's in taxes or part of our paychecks, and they are the ones who are deciding. But remember, their business model can't fail by nature of it.

So we've become, what I sort of think of as addicted to this system because there's no, to your point, direct hit that says, "Would I pay for it if I had to give you my Visa card? Would I buy it for, what may be a few months of survival or even more?" And I think that disconnect has left us in a place where as consumers, we expect to live forever and we expect to have all the access we could possibly get. Do you think there's part of that? But if that's true, then how do we break that up? How do we undo that, Derek?

Derek Raghavan, MD, PhD: I think there's a lot of truth in that. There are many, many factors that push costs up and that make this difficult.

I have spent many years working on behalf of the National Cancer Institute and being on their panels, as you have, John, and we've served on some together. The NCI by its design is somewhat risk-averse and pretty conservative, and so it's an institution that likes to keep doing the same old thing oftentimes, and has tended to use its standard models for making things better and things don't always get better. So, you know, I think government agencies need to think out of the box.

I think another big domain is the risk-reward system in health care. A second area that I think isn't going to be for the good is this amalgamation of huge systems across the country. My personal belief, and I'm sure there are many people who disagree with this, is as systems get bigger, it's harder to monitor quality and cost control. And so you get systems getting bigger and bigger, but with less checks and balances that look to the sort of quality that you might care about and that I might care about.

Over the years, a lot of the measured quality indicators are actually nonsense indicators that well-intentioned people check. They don't ask simple things like: What is the survival? How many days in hospital? How much out-of-pocket cost? What are the toxicities? How much real benefit do you get from a new drug versus an old drug?

To be honest, the journal editors are somewhat culpable here. You know, they'll take a study that's about a hot new drug. You might recall there's a drug called abiraterone that's used for prostate cancer, and some really smart people figured out at the University of Chicago that if you take that drug with a fat load, so fatty food, you need less dosing than if you just take it on an empty stomach. To get that published was no walk in the park because it wasn't sexy. On the other hand, I'm a prostate cancer doc. It's hugely important in terms of cost containment and so on.

So, doing simple studies that say, "Here's an old inexpensive drug. Let's do a phase 3 study against the newest, hottest drug and see if it really is better or not better and how much benefit there is," it's very hard to get that sort of stuff published. Also very hard to get that sort of study accepted for presentation at our very hot scientific meetings. So there are lots of different factors.

John Marshall, MD: Well, and 2 things I'll add to that are, you know, we're incentivized to treat more. And so, you know, this idea that we wouldn't want to cut back on something because, you know, even though it's not directly coming to our paychecks, it sort of indirectly is on some level. And we don't want to regret not having given somebody the optimum treatment. The patient on the other side wants to get the optimum treatment too.

And I also remember back to the good old days when the NCI would do cooperative groups, would fund the kind of trial that you're talking about, of looking at head-to-heads or dose comparisons and the like, that actually informed a great deal back in the early part of our careers, and we don't really even see those kinds of studies being done anymore. And then you're out there hanging by yourself as an old guy trying to teach young docs how to do this when that's not really how they've been trained or don't have that same experience.

But let me go, you know, should the payer? Let me be controversial. You and I have had discussions like this before. Let's say I just get a diagnosis of, I don't know, metastatic colon cancer, and I'm a Blue Cross CareFirst person, and let's say I get a call from one of their employees that says, "Hey, John, if you choose not to take treatment, I'll send you a check for $500 000," because I'm going to spend more than that on my treatment over the next few years.

There are a lot of people out there who would be offended by that phone call, but there are a lot of people out there who might say, "Sold. I'll take... I have kids in college, I could leave it for my grandchildren, I could pay off my house," and living a couple more years in that situation may not be worth it to me. But we don't have a culture where that would even be on the table, right? That's not even discussed. Even though that is my money in the bank that they're going to offer to give me back. Do you think that's crazy? Should... Is that just ethically too far for us?

Derek Raghavan, MD, PhD: I don't think it's crazy, but it needs one very important step between where we are now and that concept. And that is we need to create a much more transparent system where doctors are comfortable to have very tough discussions, and some of us are. I know your pattern of practice is that, so is mine. But I think you see a lot of people who, with the best of intention, want to have a discussion that goes something like this.

So, in your hypothetical case, we're talking about super whiz-bang drug number 4 that would cost half a million dollars. And I need to say to you, "John, I'm not going to abandon you. You need to be aware that you are now third-line metastatic with colon cancer. We've used the standards, and we have super whiz-bang drug. We think it has a 10% chance of helping you, and if it works, it might prolong your life by 4 months. Now, with that in mind, new things are coming along the pike all the time. We may have another approach, but right now I can't offer you survival that's indefinite." That's a hard conversation. You can't do it as bluntly as I just did talking to the program. But many, many people go into trials, particularly phase 1 and phase 2 studies, with the idea that if it works, they'll be around 10 years from now.

Now, to be honest, if I were, say, and I hope I don't have this issue, and had metastatic X cancer, and someone said to me, "We have a drug at this point that can have you live to be 86 or we'll give you half a million dollars and you can use it for your grandchildren's college education," pretty easy choice for me. Now that's the courage of the noncombatant, because I'm not facing death immediately, but I think we need to have a lot more of those sort of discussions.

When I came to Charlotte, I looked at patterns of practice, what I looked at, and you know, I think I'm a decent guy, but I can be tough if I'm trying to advocate for my patients. I found that we had some physicians who were treating routinely within a month of death with toxic drugs. And we had some fairly candid discussions about my view of who would be employed in the system I was creating and who wouldn't. Happy to say they were reasonable discussions. I understood their reason for not wanting to have the discussions. I explained the downstream impact, and people changed their patterns of care, and that has continued. So you can change patterns of care.

I think the mantra that I've had for my whole career is if it's good for the patient, it can't be bad, or it can't be too bad, and you try to do reasonable things. Now, the right-to-try legislation was designed to be good for the patient, but I'm not sure that it is. It puts people at risk of having toxicity, of having cost, of having a terrible death when they might have a gracious death.

But I think the reality goes back to the fact death happens, and maybe sometimes our job is to make it easier, and that can be also less expensive with less toxicity. So, in my clinical practice where I see people running out of time, I get them introduced to palliative care doctors early in the process so that it isn't a sudden last-minute handoff, but they actually know the palliative care team, they understand what it can offer, and so on and so forth. So, you know, I think these are all factors that, if you're not following that line, push the costs of care up.

John Marshall, MD: Yeah. Do you think we'll ever get to a place, maybe we're already there in some, you would know this, where the consumer begins to see the benefit of our efficiency? That if we are better stewards of the bank, so to speak, that, I don't have to put as much in coming in or... But that's a, that's to me a ways away, right? We're...

Derek Raghavan, MD, PhD: I think it depends. You know, I think when I developed the system in Charlotte, our focus was on value-based, high-quality care. We did a lot of research. We published a lot of papers. We introduced new drugs. We provided good quality care with a lot of help from you and some of the molecular diagnostic companies. You know, we developed a system-wide molecular tumor conference that actually helped patients to get onto studies where they got onto studies that were at low cost because they were part of trials that were helpful to them. We had, as I mentioned, the Financial Toxicity Tumor Conference.

So what I think is patients and word of mouth are collectively smart. If you say, "I have a health care system that is focused on patient benefit, and that includes giving you treatment when it's helpful, but not giving you treatment when it isn't helpful," will resonate with most patients. There are some who say, "Never say die. I want to keep going. I want to die with my boots on and guns blazing," and you should figure out how to help those people achieve their goals as much as you can. There are an awful lot of people who expend money for little gain and don't realize until near the end they've wasted their time, their side effects, and sometimes their exchequer.

So I think patients will respond to thoughtful advertising campaigns. One of the challenges with direct-to-market advertising is it often misrepresents the true benefit of stuff. And the flip side is, for medicolegal reasons, they put absolutely every toxicity as if it applies to everyone, and that's wrong as well.

John Marshall, MD: While they're showing a beautiful picture of a sailboat, and a nice family, so you're not listening anyway. Yeah. They're good at that.

One of the papers that I saw from this week, I'm monitoring this, is it's a cancer of unknown primary study where 1 out of 4 patients got traditional platinum-based therapy, and the other 3 out of 4 had a tumor board, like your molecular tumor board, with gene testing, and trying to tailor the therapy. Yes, it was positive, but back to our little cold water for our successes, it was a few months improvement in survival. Better than not doing it, so it was sort of to say, don't just give everybody platinum-based therapy. Precision medicine is worth doing in the cancer of unknown primary. But what we all want is that bigger hit than that few months, improvement, in outcome. So, anyway, it goes right along with what you're saying: trying to be as smart as we can be.

Let me close this out with a question about sort of what I think of as current threats. And, you know, as a member of an NCI-designated center and the kinds of cuts that are happening to basic research and NIH funding, which is sort of boring but very basic. It is the foundation on which we discover. On the other side, we have, you know, people saying, "Oh, the free market with the mRNA personalized medicines or the new RAS drugs," that they're giving credit to the companies, when in fact none of those things could have happened without the basic science understanding that our tax dollars helped pay for and fund through the US research infrastructure, which is a threat.

We see ex-US, mainly... We mostly talk about China, but it's happening in other places, too. Back to your shining star on the hill, kind of analogy, is that it feels to me like we're undoing some of the things that did make us great and we're crumbling a bit. So am I off on that? What's your take?

Derek Raghavan, MD, PhD: It's a very difficult time. You know, I think we've got health care being driven nationally by, in some domains, by conspiracy theorists absent any data. They make it seem that structured studies are a bad thing, when you and I both know and have known for decades that if they're well-structured, they're a good thing and they advance our knowledge. Money is being thrown at completely stupid, non-hypothesis-driven junk ideas, so there's a lot of junk science out there. There are a lot of publications now that are producing "data" that aren't really data for money that people will put their studies in.

I think we need to have structured funding for governmental research of high quality. I think there needs to be a lot more work between government and the pharmaceutical industry that relates to quality of science and the doctrines of science. There's a lot of real-world data out there being generated by people with secondary gain, and a lot of the real-world data is predicated on bad, routinely acquired information that supports people's preconceived hypotheses rather than really being a test of science.

We were in much better shape, in terms of the structure of what we do and the work we do before COVID-19. Downstream from COVID-19, there's so much suspicion. It's stimulated by politicians and by some domains of government inappropriately, I think it's a very sad thing.

One of the things we haven't touched on, probably for a different day, is the number of people in medicine and nursing who are leaving because they are decried by the populace at large. They have negative press for no good reason. I think that ultimately will increase cost as well, because less experienced people will be doing things that people wouldn't be doing.

So I think it's a very complex system. Ultimately, I think America operates on the basis of its electoral policy. If we elect people who are crazy, then we probably deserve what we get.

John Marshall, MD: I think with that, we will let it sit right there. Dr Derek Raghavan, thank you so much for taking some time out of what I know is a very busy day every day, and all that you have done for me personally in helping to show me the way, sort of true north, and giving me tips as well. But I'm sure all of our listeners appreciate what you have done for us today. So Derek, thanks for joining us.

Derek Raghavan, MD, PhD: Thanks for the invitation. Good to see you again, John.

John Marshall, MD: You too, sir. And thanks to all of you out there who are listening in to Oncology Unscripted. Stay tuned for even more. Thanks for joining.

This transcript has been generated by AI and lightly edited.