Lost in the debate on “Trumpcare” versus “Obamacare” is the proper consideration of the factors driving increasing health care costs. In cancer, the pharmaceutical industry plays a major role setting drug prices that exceed reasonable returns on research and development. The economics of treatment were again apparent during the plenary session of the American Society of Clinical Oncology Annual Meeting in June, aka the cancer community’s Super Bowl. Two years ago, Dr. Leonard Saltz of Memorial Sloan Kettering implored us to pay attention to the cost of drugs being presented, emphasizing during the plenary session, “These drugs cost too much!”
I kept these words in mind as I listened to the presentations this year about advances in treating prostate and breast cancer. For prostate cancer, the presentation was regarding abiraterone, which works by more effectively shutting down male hormone production. The study asked the question whether, in more aggressive cases, it made sense to start using this pill earlier in treatment. The results were remarkable, starting this drug sooner could potentially help cancer patients live for years more. These results were similar to results seen in a trial presented two years earlier, where patients with aggressive prostate cancer received an intravenous chemotherapy drug docetaxel.
Most people would not realize that the intravenous chemotherapy regimen costs significantly less than the oral medication. One month of abiraterone costs about $10,000, whereas three weeks of docetaxel including cost of drug administration, $4000, a cost difference over six months of nearly $28,000. Furthermore, chemotherapy is covered by most insurance, whereas oral medications depend upon prescription coverage.
In breast cancer, the trial presented focused on patients who have a type of gene mutation called a BRCA mutation. For these patients, research has focused on the development of a class of drugs called PARP inhibitors. The study presented about one such drug, olaparib, assigned patients to receive either olaparib or another medicine of the treating oncologist’s choice. Olaparib was better than the other medicines chosen in slowing growth of the cancer over time.
The catch, though, was in the details. Those not getting olaparib could also not be given another drug called carboplatin. Patients whose cancer had grown after receiving a platinum based chemotherapy could not participate. Why is this important? It turns out that platinum containing chemotherapy is effective in treating breast cancer patients with BRCA mutations, and it is a whole lot cheaper. The FDA approves drugs based on the parameters in which efficacy and safety of the drug was demonstrated without factoring in cost. So olaparib will likely be approved for patients who are still platinum sensitive. This, despite the fact that one month of olaparib costs about $4000, whereas three weeks of carboplatin, $1300, a difference of about $14,000 more over six months. Olaparib will be touted to patients as the next great advancement, perhaps even by direct-to-patient advertising on television during the next Super Bowl. The way this trial was designed, data comparing to carboplatin may never be available. No one will ever pay for these trials. It’s not in the drug company’s interest to conduct this trial, and no one else can afford to do it.
Should we take costs into account when it comes to advances in cancer? The answer to this lies in another presentation that occurred during the plenary session. Patients at Memorial Sloan-Kettering were randomly assigned to self-report 12 common symptoms via tablet computers between and before visits with doctors versus usual methods of monitoring. With this maneuver, which costs significantly less than drugs, patients on average lived five months longer (a greater benefit than olaparib demonstrated). Their symptoms were addressed sooner, they were hospitalized less frequently and they could be treated longer.
The support staff needed to implement these measures also cost money. How are we going to pay for these? Some point to the Medicare Oncology Care Model (OCM), where bundled payments are given to practices to provide quality patient care for meeting certain quality and value criteria, aiming to replace the traditional fee-for-service model. But OCM specifically “aims to provide higher quality, more highly coordinated oncology care at the same or lower cost to Medicare.” It expects to recoup the investments made in these mechanisms through cost savings in other areas and is not intended to increase funding per se. If more dollars are used for overpriced drug treatments, less money is left to implement more cost effective patient-centered reforms.
Nurses, psychologists, social workers and doctors are already spread thin. They need more help, and the funds needed for this should come not out of clinical funds, but by demanding that excessive drug costs be curtailed. Even if it means calling out clinical trial gerrymandering and price gouging by the pharmaceutical companies that spend millions of dollars in lobbying efforts on Capitol Hill.
Syed M. Ahmed is an oncologist.
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