At a tumor board today we discussed a case of a 80 year old woman, with a 55 year smoking history that continues to today. She presented with moderately severe chronic lung disease and a lung mass that impinged on her bronchi. A biopsy showed this to be a non small cell lung caqncer. There were several small indeterminate satellite lesions that were thought likely to be tumor–too small to biopsy.
The pulmonologists thought her poor breathing capacity eliminated the possibility of surgery to remove the tumor. The surgeons also didn’t think the tumor was resectable. The radiation oncologist thought she should have a PET scan to see if her disease was curable with radiation treatment–highly unlikely in similar cases even in the best of circumstances. His thinking was that he would use different technique if the disease were not local–though the CAT scans already showed several suspicious lesions away from the original tumor site.
It should be noted that PET scans often miss small metastatic lesions and if positive require biopsy confirmation. So a negative PET showing no spread would have a good chance of being incorrect. And a postive PET would require some confirmation to act on it. All this in an 80 year old with non-resectable lung cancer.
That decision to do a PET scan costs about $4000 in our institution. The range of cost around the country is between $3000 and $6000.
In no other endeavor involving individuals are such expenses incurred, with so little consideration of expense and in this case with so little expectation of a successful outcome. It’s one of the reasons our healthcare costs in the last year of life are excessive.
In the woman’s case above it could be reasonably argued that the chance that this tumor was local was virtually nil and that she should be palliated with local irradiation to relieve the tumor related respiratory symptoms and then treated symptomatically.
In my view she has no chance of cure whether she has the PET scan or not.
Can we afford such testing? Where do guidelines end and physician judgment begin? Don’t we pay physicians to excercise judgment and don’t they need to include cost efficacy in their patient care decisions?
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Medicynic 
Paul,
Very thoughtful and provoking discussion.
This issue comes up both in government and market systems. It comes up in a market system because if private insurance covers everything over the deductible then it raises costs for the others who have bought the same policy.
Of course there is no problem, perhaps, if the individual is paying themself. But this is extremely rare.
We can imagine a government board making decisions as to whether a procedure was good value in certain situations so that individuals could buy policies that cut off at certain value points.
However, your analysis of this specific, complex case makes it very hard to see how a government board could fine-tune an algorithm to decide the cost value. How do you feel about this?
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Paul, I participate in a health care listserv: Health Reform Discussion List at lsv.uky.edu. Would it be OK with you if I copied this posting and my response to that listserv? Also, you might enjoy the discussion on that site. It is currently rather sparse, but there is a doctor/pathologist, Dr. Bill Palmer, whose comments are usually very provocative. The dominant ideology is market-driven, but there are a few dissenters.