This is reflective of our “predictably irrational” behavior described and popularized by behavioral economist Dan Ariely, who notes that people consistently value avoiding harm or loss more than gaining equivalent benefit. We are irrationally risk-averse to the point that we make poor choices for our long-term outcomes because of it. At the same time, in a world in which the FDA or individual physicians are vilified for harming a patient, the negative consequences are truly far, far greater for harming one person by an error of commission (even if it was an appropriate judgment of risk but an improbable outcome) than by failing to offer a treatment that could help someone significantly. Nobody gets sued for failing to cure a challenging cancer.

What makes it even harder is that our brains are programmed to gravitate to stories and individuals. Strong evidence with data from hundreds or thousands of people is all good and well, but patients are unduly swayed by the story of a treatment that happened to work for their friends cousin, or hearing a story on the news of a mother who is certain that a vaccine caused her child’s autism. Cancer care institutions also market this to good effect by portraying romantic, non-representative anecdotal reports of remarkable results in individual patients. So do lawyers or politicians, who highlight a sympathetic patient who has had a bad outcome, or the sweet face of someone who they contend would be subject to a “death panel”. A compelling, data-driven argument doesn’t stand a chance.

Sadly, even doctors trained in evidence-based medicine are still often convinced by the before/after images in the “case study” of an individual patient doing well on a particular new treatment or the relay of a colleague’s great result from a particular strategy than from the strength of the best evidence from a broader but faceless population.

But failure to recognize our predictably irrational behavior of avoiding harm by an act of commission but allowing 10 or 100 times as much harm by an act of omission, and by falling prey to the seductive appeal of an anecdotal report to outweigh all of the best evidence. But having 10 people die from progressing cancer to ensure that one never dies from the treatment isn’t a noble or wise decision. In the end, what we have is a system that reflects the incentives acting on it. We could help ourselves by recognizing that our current system of extreme protectionism is killing us with kindness.

Sadly, I’m seeing and living a very different and clearly destructive economic model in the pricing of cancer care.   Every new drug being released sets a higher bar for cost and poor value.  The problem is that, in the US at least, we are almost completely insensitive to the cost of cancer treatments, and pharmaceutical companies are therefore pricing these agents accordingly.  Chemo agents have drifted from a few thousand dollars per month to new benchmarks of approximately $10,000 per month for treatments that aren’t curative but confer a prolongation of survival that may hover in the range of 2-4 months.  Dendreon’s Provenge (sipuleucel-T), a vaccine-based treatment for prostate cancer that is associated with a median survival benefit of four months, weighs in at $93,000 for the three planned infusions, while Yervoy (ipilumumab), an immune-based therapy for melanoma, confers a similar palliative benefit for $120,000 for the treatment.   And those at least offer a survival benefit.  Companies providing a “supportive care” therapy that reduces the risk of nausea, or skeletal fractures from bone metastases have also found that they can escalate the cost of their drugs to hundreds or even thousands of dollars per treatment cycle (typically around 3 weeks) without enough resistance to incentivize them to provide meaningful value over what preceded them.  Beat the current standard of care marginally and double the cost: what will people do?  Not pay?  Hell, no…it’s cancer, so the health care system has to pay, no matter what the cost or lack of value.

Of course, this is completely unsustainable, and the US economy is being crushed under the weight of ever-escalating cost of health care, with cancer care the leading area where costs just keep accelerating.  Patients and caregivers are also motivated to receive everything with evidence to support it, and many also seek commercially available approaches that aren’t supported by evidence, and without needing to pay a significant proportion have little reason to pursue less than everything possible.  Physicians and institutions are financially incentivized to provide as much care as possible, including everything that is indicated by good evidence, and also many things that aren’t but can be covered by insurers.   Pharma and medical device companies are delighted that nobody has the ability to challenge the costs of these interventions, lest someone shout “health care rationing!” any time someone suggests that it might be appropriate to ask whether paying any amount in the world for a marginally useful treatment might not be a reason to bankrupt the country.   And insurers don’t want to be featured in the media as bad guys not willing to pay $200,000 for a bone marrow transplant — even if it’s in a situation in which there isn’t any evidence it’s helpful.  It makes a good story to show a poor young woman with a bad cancer, and a face on the nice patient is far more compelling than someone talking about the costs from a faceless insurance company…

I would argue that there is no setting in which we get less for our money, by a system in which all principal stakeholders (pharma companies, patients, caregivers, doctors, health care administrators) have unfathomable biases and conflicts of interest, and in which the general public is less able to make rational decisions, than in cancer care.   We’re all out at a massive dinner together where the check is being split, so everyone wants to ensure that they get not only a dinner but two extra appetizers, a fancy bottle of wine, two desserts, and a $200 glass of port afterward.  After all, who wants to be the sucker who ordered soup and then still has to pay an equal share?   But people can’t connect the dots between the mindset that “everyone should have every treatment for everything, forever” and the fact that companies are being ruined because they can’t afford the costs of health care, and household budgets are being ravaged because those insane costs paid by insurance companies are being passed right back on to the people being covered.

This feels like someone is just pressing the accelerator as we speed faster and faster into a wall.  Unless the US population fundamentally changes the presumption that rationing of care and a testing of value are complete anathema, the cost of health care, with cancer leading the way, will do nothing short of ruin us.

That said, we are only now entering a time when high speed internet is so pervasive, while more and more people now have Facetime and Skype readily available and being used on their phones, laptops, and tablet computers that it’s becoming feasible for a much broader range of the population to interact via video-based teleconferencing effortlessly. It’s no longer the tech-savvy gadget people doing this. Like many other grandparents, my folks are now using Skype to communicate with their grandchildren. Folks in their 70s, as well as kids under 6, are now doing video chats. And it’s only when the technology becomes so easy it’s boring that it really takes off.

For years before digital cameras or e-book readers took over the world, we read articles saying “the technology seems to be there, yet it isn’t catching on yet. Will it ever really happen?” It did, and the new technology became completely disruptive. All of the elements are in place for telemedicine to transform how health care is practiced, and in the next couple of years, the articles will cover the changes that are actually being realized, rather than just the promise of telemedicine.