Directing cancer resources in a limited resource world

american cancer societyAs we walk the halls and sit in the lectures at the annual meeting of the American Society of Clinical Oncology, there’s an elephant in the room. It is right there in front of us, but not many of us seem willing to talk about it. Fewer still are making any commitments to do something about it.

So what is this ubiquitous juxtaposition that is right in front of us but we can’t seem to see?

It is the contrast between incredibly sophisticated science and computer data that will help us understand cancer and its treatment versus the reality that we can’t have medical records that really work. It is the fact that we have million dollar machines to treat cancer but we have tens of thousands of lives lost to cervical cancer in underdeveloped and underserved countries that could be saved with saved using vinegar. It is cancer care’s version of the “guns versus butter” debate of the 1960s.

There was a large plenary session where thousands of people from around the world sat and listened to the “top” abstracts presented to the assembled masses. These 5 papers represented what the meeting’s scientific advisors thought were the best of the best, the ones with the most impact. There was also a major award lecture by Dr. Charles Sawyers from Memorial Sloan Kettering Cancer Center who discussed his research on understanding resistance to treatment in advanced prostate cancer.

The paper that got the most audience reaction was a discussion of a cervical cancer screening program in India using vinegar applied and evaluated by trained non-medical community health workers. The study which was conducted over many years reduced deaths from cervical cancer by 31%. Applied to the underdeveloped world, another expert reacting to the presentation extended the research to claim 250,000 lives a year could be saved worldwide.

Granted, this was an excellent study performed in a “low resource” country in their most destitute women, with many cultural and religious barriers that had to be overcome. But it was indicative of the impact some basic blocking and tackling can have in reducing cancer deaths.

Oh, but you say, that doesn’t apply to the United States. To a degree you would be right. We do a pretty good job in this country of screening women for cervical cancer. But we don’t do a great job. This year, 4,030 women in the U.S. are expected to die from the disease. And most women in the U.S. who do develop cervical cancer have not been screened in the recent past.

The sad reality is that for other cancers where screening works, we could do much better and could save many lives. There are estimates that today we could reduce deaths from colorectal cancer by 50% if we got everyone screened. On the other hand, we spend a fortune on prostate cancer screening and treatment and it isn’t clear how much of a difference we are really making.

Then there is the question of what happens once we find a cancer. In Atlanta and other cities across the country, too many women diagnosed with breast cancer never get treated. They get lost in the system. Does anybody care about these women? Does anybody call them? Does anyone reach out and gently help them through the system with sensitivity so their lives can be saved? In that study from India, one of the conditions was that women diagnosed with cervical cancer were guaranteed treatment at the hospital running the study, a common protocol here in the U.S., as well. But what about women in the United States and elsewhere not taking part in such a study? Are they guaranteed care?

Get the message? We have great science. We have great hope. We are taking that hope and applying it to new drugs and new treatments for cancer that hold the promise of saving lives. But we can’t get a patient or their medical records from point A to point B.

These new drugs when they come to market are costing $100,000 a year or more. Dr. Sawyers pointed out in his lecture yesterday that it strikes him as odd that we haven’t taken a page from the treatment of infectious disease and HIV, where combination treatments are more effective than single drugs. In targeted therapies for cancer, monotherapy (single drug treatment) is the rule, not the exception. He then called on researchers to engage the question of multi-drug treatments to reduce resistance, but wondered out loud how we could pay for it.

What happens if two or three or more of these drugs together work incredibly well? In today’s scenario, that means hundreds of thousands of dollars A YEAR–and that is just the cost of the drug. Don’t forget there is a lot of other care that is required to care for a patient with advanced cancer.

Dr. Sawyers also “called out” the pharmaceutical industry for their high drug costs during his lecture. He made mention that their current business model to maximize profits would suffer from multiple drugs used together. He then issued a call to action for the cancer community to start agitating the same way AIDS advocates did a number of years ago, when the drugs were also very expensive and used as single agents. Over time, multiple drug therapy became the rule and agitation resulted in a substantial reduction in costs–not to mention it did largely convert a fatal disease into a chronic one.

The question still comes down to the basic issue of guns versus butter: how are we going to direct our resources in a limited resource world going forward? Are we going to spend more and more money on drugs that help a few (the military expense for big weapons in the guns/butter debate) or spread our resources to more people where costs would be less (read that investments in prevention strategies, better health information technology, better effective cancer screening and access to basic and necessary medical care which is the “butter” of that debate)?

I would suggest that the elephant in the room may soon become very visible. We are going to have to make choices, and it will tell a lot about us as a nation and society as to how we make the choices we will inevitably have to make. The decisions we had to make back in the 60’s whether we would spend on big stuff or routine stuff are still with us today. In cancer care, it is only going to get more difficult to make those decisions.

So the question is no longer “if,” but “when.” And “when” may be sooner than most people think.

J. Leonard Lichtenfeld is deputy chief medical officer, American Cancer Society. He blogs at Dr. Len’s Cancer Blog.

View 2 Comments >

Most Popular

Get KevinMD's 5 most popular stories.