Who pays for hope? – treating cancer early

There has been progress with new treatments where we see cancer mortality rates slowing more than incidents, but many new oncology drugs are studied only in the late metastatic stages of the disease, and the increasing challenge is should we use these new drugs at earlier stages of treatment. As the newest, best drugs are often used when the outlook for patients is the most poor, should we investigate their use when the cancer can actually be removed earlier with surgery or often by standard chemotherapy, which would be as an “adjuvant”, serving to aid or contribute to an earlier cure or treatment? Does earlier treatment work? Trials studying earlier settings will often rely on other endpoints than overall survival which will lead some payers to challenge the value of the drug and study. By using a proxy to overall survival, would payers be paying for hope? Where does the patient sit in this decision?