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Dr West

Frogs in boiling water: On breaking the $10,000 barrier

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Note: Novartis has provided funding to GRACE for our recent ALK-positive patient forum.

Last week, the FDA approved Zykadia (ceritinib), the second generation ALK inhibitor.  As I wrote in my post about this new agent its rapid approval as the first effective treatment for acquired resistance to a targeted therapy in advanced lung cancer, there should be little question that it provides a helpful new option.  A couple of days later, I learned the cost: $13,500/month.

I felt some sticker shock over this. After initially being shocked at the price of EGFR inhibitors at around $5000/month, then having then escalate every few years, we saw the approval of XALKORI (crizotinib), setting a new pace in lung cancer, at $9800/month. Though that represents a heady range, we cou;d also potentially justify the cost by saying this was a very limited population and that criotinib provided a profound benefit. 

I was shocked about the cost of Zykadia, at $13,500, which made the $9800/month cost of XALKORI seem quaint, like a relative bargain. I expressed my concerns to the folks at Novartis, saying that I thought the price was aggressive and approaching extortionate, especially after the FDA approved the drug just a couple of years after it began phase II testing, based on just 140 patients, not the typical requirement of large, expensive phase III trials over many years that provided the justification for the high cost of these drugs in the past.

To their credit, they were very responsive and got back to me about my concerns.  They made several points that made me feel as though the question of cost and value for cancer agents is a fair concern, but also that their pricing was a thoutful process, what they estimated as fair market value relative to other agents and not just a simple opportunity to demand the absolute most that could be obtained.

Novartis pointed out that the evidence with Zykadia shows it is more active than XALKORI. It’s absolutately true that Zykadia is associated with the same response rate in ALK-positive patients of about 60%  but active in both XALKORI-naive and XALKORI-resistant patients, and also leading to responses in the brain that aren’t seen with XALKORI. They noted that XALKORI has also increased in cost by 10% since it was initially introduced, so it is now approaching the $12,000/month range, and that a reduced dose of Zykadia is associated by a reduced cost. In other words, if many patients end up taking 600 mg instead of 750 mg/day as their ideal dose, the cost is $10,800/month, which is less than the current cost of XALKORI. 

Framed in this way, I came to the conclusion that Novartis certainly hasn’t dramatically escalated the problem of remarkable cost of targeted therapies for cancer drugs, even if they turned cost pressures downward.   We’re becoming like frogs in slowly boiling water, accepting rather than challenging our destructive fate because it’s happening gradually.Frog in Boiling water

So we’re seeing the cost of cancer drugs now regularly in or exceeding the range of $10,000/month, rising at a rate that is unsustainable if we want to continue to have roads and schools and pay for anything other than health care.  At this high cost, even people who believe that these drugs provide encouraging benefit to patients may feel guilty that the costs are astonishingly high for society to bear.  Moreover, this cost level means that patients may be paying monthly co-payments in the thousands of dollars every month, and many patients in the US and especially other parts of the world may not be able to receive them because of the prohibitive cost.

Unfortunately, these drugs are only effective to the extent that people can actually receive them, and cost is a barrier we must address to realize the promise of these targeted therapies.  

5 Responses to Frogs in boiling water: On breaking the $10,000 barrier

  • Alissa says:

    Dr. West, our oncologist wants to start my husband on “Zykadia”. The pharmacist has requested it from Novartis, but it seems to be unavailable. Any idea on how long it will take to get this “on the shelves” and helping people?


  • Dr West
    Dr West says:

    My clinic nurse is working on getting access for one of my own clinic patients right this minute.

    I have reached out to someone from Novartis and will relay back when I get an answer. I’m sure you’re not the only one in this predicament.

    -Dr. West

  • Alissa says:

    Thank you!

  • Dr West
    Dr West says:

    Here is the response I just received:

    Good to news to share! Product was released yesterday from Novartis and will arrive to McKesson Specialty this morning. Specialty pharmacies have already placed orders. Patients should receive Zykadia as early as 5/20, surely by Memorial Day.

    Please remind patients to pick up their phones as the specialty pharmacy will call to confirm/schedule delivery, etc.

  • Alissa says:

    FYI – Joey got his prescription filled today….$16889.30 ….Luckily not our cost. He takes his first dose in the am.

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