Therapy Preferences in Melanoma Treatment - Willingness to Pay and Preference of Quality versus Length of Life of Patients, Physicians and Healthy Controls

Background New melanoma therapies, like e.g. ipilimumab, improve survival. However, only a small subset of patients benefits while 60% encounter side effects. Furthermore, these marginal benefits come at a very high price of €110’000 per treatment. This study examines attitudes towards melanoma therapy options of physicians, healthy individuals and patients, their willingness to pay and preference of quality versus length of life. Methods Based on findings from a focus group questionnaires were developed and pretested. After obtaining ethical approval and informed consent surveys were conducted in a total of 90 participants (n = 30 for each group). Statistical analyses were conducted using R. Findings Attitudes vastly differed between healthy participants, physicians and melanoma patients. Whereas melanoma patients show a high willingness to endure side effects despite very small survival gains (down to 1 extra week) or even only hope with no survival benefit, healthy controls are more critical, while physicians are the most therapy adverse. Consequently, if given €100’000 and the free decision what to spend the money on the willingness to pay for therapy was much higher in the patient group (68%) compared to 28% of healthy controls and only 43% of the physicians, respectively. When lowering the amount of cash that could be received instead of ipilimumab to €50’000 or €10’000 to test price sensitivity 69% (+1%) and 76% (+8%) of melanoma patients, respectively, preferred ipilimumab over cash. When judging on societal spending even melanoma patients opted for spending on ipilimumab in only 21%. Conclusion The judgment about the benefits of new treatment options largely differs between groups, physicians being the most critical against therapy. Price elasticity was low.

Imagine there was a medication that made perfect health until the end of life possible. However, you would have to pay the treatment with lifetime and sacrifice some life years. Supposed you were going to get 80 years old, but had sanitary limitations such as daily pain in the back. You could be perfectly healthy until the end of your life with the medical preparation, if you renounced for example 5 life years and were only going to get 75 years old, but without any complaints 3.) I would be prepared to sacrifice ____________ life years, if I could live free of any sanitary complaints until the end of my life.

Please put yourself in the following situation
You have an advanced malign melanoma, which has already metastasized into inner organs. You suffer from pain in your bones, breathing difficulties and depression. You are educated that you suffer from an uncurable disease and that the average life expectancy in this stage of the disease rarely exceeded 9 months.

Therapy A -new drug
Your physician explains that there is a new drug that 10% of all eligible patients respond to, i.e. the tumor is getting smaller or disappears. On average patients live two months longer with this therapy. There is no chance for a cure. In more than half of all cases treatment-requiring adverse effects such as diarrhea, liver inflammation, hormone disorder, psychological symptoms, nausea, vomiting, severe abdominal pain and skin eruption occurred. The total therapy costs amount to about 120.000 Euro. The health insurance funds bear the costs.

Therapy B -standard chemotherapy
You are also educated about the standard therapy with chemotherapy that 6% of all eligible patients respond to, i.e. the tumor is getting smaller or disappears, whereby existing ailments could be alleviated. There is no chance for a cure and it is not prolonging life. Common side effects were loss of appetite, nausea, vomiting and alterations in the blood count. The price for a therapy cycle of three infusions of chemotherapy was about 10.500 Euro per therapy cycle. The health insurance funds bear the costs.

Therapy C -palliative care
Your doctor also offers you to enroll yourself into a palliative care program. Palliative care attends soothing pain and relieving discomfort as a consequence of the cancer in an inpatient or an ambulatory setting. Furthermore you receive psychological and clerical support at your request. You and your family will be advised and supported in medical, financial and social questions. By means of the cooperation of nurses, physicians, social workers and clerics a much more personal care than in a standard clinic is permitted. The costs lay within the range of 4.900 Euro on average per patient per year. The health insurance funds bear the costs.
Please decide for each pair of options which situation you would rather choose.

4.)  Either two months of life with mild side effects with chemotherapy (Therapy B -chemotherapy)
 or four months of life with medium severe side effects. (Therapy A -new drug)

5.)
 Either eight weeks of life with mild side effects with chemotherapy (Therapy B -chemotherapy)  or nine weeks of life with medium severe side effects. (Therapy A -new drug)

6.)
 Either four months of life with medium severe side effects (Therapy A -new drug)  or three months free of complaints without any tumor therapy with social care at your request. This includes the possibility of visits by a cleric several times a week, financial consultancy by social workers, inclusion of the family in consultancy offers and a more personal care by nurses who have more time per patient available than on an ordinary department. (Therapy C -Palliative care)

7.)
 Either three months with mild side effects with chemotherapy (Therapy B -chemotherapy)  or three months free of complaints without any tumor therapy with social care at your request. This includes the possibility of visits by a cleric several times a week, financial consultancy by social workers, inclusion of the family in consultancy offers and a more personal care by nurses who have more time per patient available than on an ordinary department (Therapy C -Palliative care) The pharmaceutical industries have set prices for the presented therapy A (new drug) of about 120.000 Euros per treatment cycle. Since the financial resources of the health fund are limited, in daily life it has to be weighed in which case the new drugs should be applied.
Please indicate only one option in the following multiple choice questions.

8.)
If you were authorized to decide upon the investment of 1.2 Mio Euro of our health fond, which decision would you take?
 A) I allow for the palliative care 245 patients by a specially trained team, whereby a better quality of life, but no life prolongation can be achieved.
 B) I invest in the new treatment and allow for a two months longer survival for 10 patients.  C) I allow for 7500 skin screening examinations, in order to detect about 28 malign melanomas early, when a cure is possible.
 D) I invest in prevention measures for the long-term decrease of melanoma incidence by 50% in 10 years.

10.)
If you could choose between receiving 100.000 Euros in cash or therapy A, how would you decide?
 A) I would choose the new treatment option therapy A.
 B) I would renounce on any therapy and prefer the money in cash to fulfill myself one last wish or not to have any financial worries anymore.

11.)
If you could choose between receiving 50.000 Euros in cash or therapy A, how would you decide?
 A) I would choose the new treatment option therapy A.  B) I would renounce on any therapy and prefer the money in cash to fulfill myself one last wish or not to have any financial worries anymore.

12.)
If you could choose between receiving 10.000 Euros in cash or therapy A, how would you decide?
 A) I would choose the new treatment option therapy A.
 B) I would renounce on any therapy and prefer the money in cash to fulfill myself one last wish or not to have any financial worries anymore.

Therapy decision
Please decide for each statement separately if you agree, even if the statements seem to be similar.
Please indicate only one option per statement.