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Over the past couple of months, there has been a lot in the news, both for the lay public and targeting physicians, about the recommendation by the Oncology Drug Advisory Committee (ODAC) to remove the FDA approval of (Avastin) bevacizumab for breast cancer based on the lack of demonstrated survival benefit. Not surprisingly, this has been a contentious recommendation that has been criticized by many breast cancer patients and advocates, including physicians.

There is no question that having an approved indication rescinded is a big deal, as it is always problematic to lose an opportunity or privilege that was previously offered. While likening the potential loss of an FDA approval for breast cancer has been heralded as an early step in a dreaded march toward rationing of health care and the beginning of death panels, its use in breast cancer has demonstrated a very different slippery slope. Despite the fact that this is a very expensive medication with potentially significant toxicities that did not demonstrate a significant benefit in overall survival, even in the ECOG trial that led to its approval. Moreover, as we might expect with a commercially available option, this approval leads to a slippery slope of use outside of the indication, such as continued therapy after a patient progresses on it.

As we weigh the value of cancer treatments, I think it is fair to question whether we can and should pay for every single treatment that provides benefit in any measurable endpoint. There is certainly some value in prolonged progression-free survival (PFS). However, it is an unfortunate reality that, despite the firestorm of hyperbolic rhetoric generated against anyone who questions the use of any medical intervention of dubious value, the financial resources we can muster to pay for health care are finite. The rest of the world has come around to the fact is that we actually do need to prioritize treatments by what benefit they provide for what they cost, and it is largely due to our collective delusion to accept this that our economy is in the dire shape it is.

Treating lung cancer is no great bargain by any stretch of the imagination, but lung cancer treatment standards have almost exclusively been defined by improvements in overall survival (OS). Discussions of the potential merit of maintenance therapy fell on completely deaf ears before a significant OS benefit was seen, despite the fact that there was a doubling of PFS. Meanwhile, there have been studies for years that have shown a significant improvement in progression-free survival with maintenance therapy for SCLC, but there has never been momentum for that approach, because it didn’t improve OS. Meanwhile, Erbitux (cetuximab) fails to generate much traction even in the face of a trial that showed a statistically significant (though not as clearly clinically significant) improvement in OS with its addition to cisplatin/Navelbine (vinorelbine) in the FLEX trial.

As many in the breast cancer community are up in arms about this insult, it’s hard for me to understand why we should have different acceptable endpoints depending on whether we’re treating one cancer or another. If discussions of treatments that improve PFS but not OS for lung cancer never get off the ground, why should Avastin be paid for in breast cancer, from first line and then very often beyond, just on the basis of that same PFS benefit? Why is lung cancer screening not standard in the absence of a proven OS benefit, but MRIs for breast cancers become routine with no demand for survival benefit to be demonstrated? If we aspire to make evidence-based decisions, we cannot make judgments about the relative importance of clinical endpoints selectively, depending on which cancer population we are studying.

Surveying the oncology landscape, what you see is that US society essentially feels that some cancers are simply more worth treating than others. Rather than have the clinical efficacy data direct where our resources go, decisions are adulterated by media hype and political expediency that allow the victims of some cancers that enjoy wealthy advocacy efforts and bask of the most favorable media attention to receive less critical assessment of value, at the expense of the especially unfortunate victims of not only cancer, but the wrong kind of cancer. And rectifying that situation is a far cry from creating death panels. It’s not wrong for us to all play by the same rules.