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New York Times Front Page Article on Cost vs. Benefits of Cancer Treatments

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Today’s NY Times included a high profile article about the difficult balance between the clinical value of some expensive cancer therapies and their financial value. I think it did a fair job of portraying both sides of the issue — that therapies like avastin, erbitux, and others are certainly priced aggressively for the modest but generally convincing benefits they provide, leaving some people wondering whether they have enough impact in a non-curative setting to justify the rather high costs. Contrasting this with inexpensive medicines (such as if an off-patent chemo were found to be modestly helpful) or expensive medicines that can be expensive but seem convincingly justified by the striking benefits (such as gleevec for chronic myelogenous leukemia, or CML), the authors offer that the costs to the patient personally can be daunting if they are paying 20% of what amounts to thousands of dollars per year, and of course also the costs to society. While countries with single-payer medical care, ranging from Canada to the UK to many/most other parts of the world, have faced questions of whether expensive cancer drugs that don’t increase the cure rate are “worth it”, the US system has not had to face much means-testing.

But with costs of cancer treatments rising rapidly, and with many competing needs, such questions are creeping into US-based discussions more and more. In the commentary about the plenary presentation of the FLEX trial that demonstrated a modest but statistically significant survival benefit in advanced NSCLC, Dr. Tom Lynch from Massachusetts General Hospital was charged with the task of providing some context about whether the 1.2 month survival benefit could justify the anticipated costs.

I think we’re going to be facing more and more of these hard questions, ones for which I don’t have any good answers. As the article notes, through the words of one of the quoted physicians (Dr. Eric Winer, a breast cancer specialist at the Dana Farber Cancer Institute in Boston), we may conclude that the cost-benefit (now financial as much or more than our usual mindset of weighing risks of side effects and quality of life issues vs. improved response rate and survival) is not favorable for society as a whole, but you have a different perspective when you have a patient looking for options in front of you.

I wonder whether the cost of things like co-payments that may run into thousands of dollars is now a factor for patients and their families. I certainly hear patients and families express a desire to explore “anything, regardless of the cost”, but is this really something that just doesn’t or shouldn’t enter into the picture? I can understand a “go for broke” (literally) approach much more in a curative setting, for which we really haven’t seen much controversy. But would people be willing to have their families go into debt for a non-curative treatment that would be expected to extend survival by 2-3 months? Is it more the hope that a person will be one of the major beneficiaries that gets many months or even years of benefit, and it’s not possible to put a price tag on hope?

These aren’t pointed questions for which I have a presumed answer. I can’t say how I’d feel if it were my father or wife or closest friend facing cancer. But I’m interested in hearing from people who face advanced cancer themselves or in someone very close to them, “is there such a thing as a cancer treatment not being worth it financially?”.


14 Responses to New York Times Front Page Article on Cost vs. Benefits of Cancer Treatments

  • neilb says:

    I read the article earlier today and considered raising it here, so I’m glad that you did. As an advanced cancer patient, I’m not sure how I will react if and when a choice has to be made that impacts my family’s future financial security (but I have wondered about that).

    Stepping back from that, for a moment, though, I don’t think the article does justice to the question of how the benefits from (for example) Avastin are distributed. I think you could make a case that a really costly drug that extended the life of every patient by two months is probably not worth it. Of course (and both Dr. West above and the NY Times article allude to this), that’s not the way it works. Avastin increases median surival by about two months, but it seems to be harmful to a minority, have no effect on a huge bunch, help some a little, and help a few an awful lot. In effect, it may move some patients into the “chronic disease” mode (same could be said for Tarceva). That’s an entirely different ball of wax. For one thing, if Avastin doesn’t help, that is obvious fairly quickly.

    One of the exciting things about NSCLC treatments right now is the potential for tailoring them to individual patients, histories, histologies, etc. I’m not sure the NY Times article quite does justice to that possibility.

    I think that uneven distribution of benefits makes this a more complex issue.–Neil

  • Dr West
    Dr. West says:

    I don’t think I mentioned it very explicitly in my discussion, but Neil brings up the gulf between approaching an issue as a population (the improvement in median survival for 100 or 1000 patients) and that of seeing how an individual patient does. Individual patients have results all over the map. I tend to strongly encourage my patients to pursue tarceva, for instance, not because the median survival benefit is astounding (a respectable but not electrifying two months), but because we see some patients go two, three, or more years on it without progressing.

    Thank you for making the point more clearly for me, Neil.

    -Dr. West

  • recce101 says:

    The NY Times is at the top of my morning browsing list, and that’s the first article I read today. I found it to be balanced and thoughtful. But the question is broader than the exploding costs of new cancer treatments — the retirement of the boomer generation is damaging the entire structure of support for seniors in this country and elsewhere. It may not be fashionable to say so, but I have a lot of sympathy for the bureaucrats, insurance executives, and others making those hard cost-benefit decisions. I could go further out on a limb and say I don’t think the medical profession does us any favors when life expectancy is extended without an accompanying increase in the number of active, productive years.

    “I certainly hear patients and families express a desire to explore ‘anything, regardless of the cost’…” Many families probably feel that’s what they’re expected to say, especially if there’s been no prior discussion with the person who is now the patient. But I wonder how many patients actually feel that way? I imagine that depends to a large degree on their personal philosophy and beliefs, how they see their lives fitting into the larger “all that is” picture, things we probably can’t get into here.

    And for something like cancer, I think it also depends on the age of the patient. If I were a parent in my early 30s with young kids to raise, I’d be more inclined to “go for broke” than I am at 72 after having already lived a full and satisfying life. “Is there such a thing as a cancer treatment not being worth it financially?” For me, absolutely, if it will jeopardize my family’s financial security.

    Aloha,

    Ned

  • Terryl says:

    I have to agree with Ned. I think there would come a time that enough is enough. I am one of the fortunate people who has affordable medical insurance through my employer, with co-pays I can well afford. Would I put my family into a position of financial jeapordy for a treatment that promises only a few months, or less? I would like to think not. I hope I never have to make that decision. I especially hope that no one in my family is forced to make that decision for me, should I be unable to make the decision myself. I can only imagine the agony of having to choose between extending the life of a loved one for a brief time or my own financial future.

  • Dr West
    Dr. West says:

    Thank you for those comments. I definitely agree that my younger patients with small children at home are more inclined to pursue potential benefits of almost any magnitude, while patients in their 70s or later often weigh the pros and cons with a more skeptical eye — looking at side effects and costs more judiciously. Of course, that’s a very basic generalization with plenty of exceptions. And you’re right to ask about the quality of life during that improvement in survival. Although the NYT article focused on avastin, the FLEX trial results have really opened a debate in the lung cancer community about whether such a median survival benefit is worth the often severe rash, risk of hypersensitivity reactions, and the need to get treated weekly, including “maintenance” therapy every week until progression.

    I want to thank you, both Ned and Terryl, for having the courage to say that the questions and challenges that the bureaucrats and insurance company leaders face are fair. Back when I was watching “Sicko”, I felt that the health care system and insurance was too complex of a subject to distill into good guys and bad guys. I’m very concerned that the combination of the rapidly escalating cost of medicine (and cancer care is growing faster than almost any other aspect of health care) combined with the growing elderly population is setting up a real perfect storm…even worse if many oncologists decide it’s not worth staying in the field.

    I don’t have any easy answers, but I think it will necessitate changing to an approach in which treatments need to provide a certain level of value, and not improve survival minimally and at any cost.

    -Dr. West

  • neversmoker says:

    I didn’t read the article, but apparently my oncologist did. He informed me that frequent imaging to determine progresion(MRI, PET, Bone scan every two to three months) for my stage iv nsclc with bone mets was a “waste of resources” and he would no longer prescribe them. It was one of the saddest things I’d ever heard in my life and completely shortsighted if you consider the cost of imaging v. the cost of treatment for one month–I could have scans nearly every month for a year for roughly the same cost as one month of treatment. If the tests saved even one month of an ineffective treatment, the tests would be a bargain for my insurance company. If this is the prevailing attitude among lung cancer specialists, it’s a wonder patients do as well as they do. Dr. Schiller (spelling?) presented a study in 2007(?) that evidenced a stigma toward lung cancer patients among family practitioners. I think it’s high time someone studied lung cancer specialists attitudes toward their patients. It’s hard enough to fight lung cancer, we shouldn’t have to fight our doctors for aggressive treatment.

  • Dr West
    Dr. West says:

    It’s not a prevailing view that oncologists aren’t inclined to do imaging studies on lung cancer patients receiving treatment, but there is controversy about whether there’s a value in doing multiple PET scans or bone scans or MRIs over time. The standard is most commonly CT scans every 2-3 cycles, but in some places CTs are done over longer intervals and chest x-rays are used in between. While some use PET scans, there’s no evidence that you do better by using super-sensitive imaging to find progression that isn’t detectable with a CT, which already shows a good bit of detail. The main reason I rarely use a PET scan for ongoing follow-up of metastatic disease is that I don’t want to discard a useful treatment too early, and my interpretation is that if the progression is so subtle that it can only be detected on a PET and isn’t visible on CT, that may be too little progression to abandon a well-tolerated approach. Our treatment options are limited, so we often don’t like to look high and low for any scant evidence to say a treatment’s not working.

    But that wasn’t really your question. I think that the attitude you were hearing isn’t representative of most people in oncology, but it’s more prevalent among primary care physicians and pulmonologists who have historically been rather nihilistic about the value of treating lung cancer. But educating people that treatments are tolerable and provide clinically meaningful benefit helps, and we’re seeing a gradual erosion of the stigma. I’m not saying it’s great, but I’ve been watching the field for about a decade, and I see reason to be encouraged that the lung cancer community, both physicians and patients (ideally working together), is becoming more galvanized and gaining momentum. It’s not great, but it used to be just awful, and it’s getting better, especially over the past couple of years.

    -Dr. West

  • gpawelski says:

    What may limit the effectiveness of Avastin is that there are multiple ways by which tumors can evolve that are independent of VEGF and independent of angiogenesis. Tumors can acquire a blood supply by three different mechanisms: angiogenesis; co-option of existing blood vessels; and vasculogenic mimicry. All must be inhibited to consistently starve tumors of oxygen.

    Instead of growing new blood vessels, tumor cells can just grow along existing blood vessels. This process, called co-option, cannot be stopped with drugs that inhibit new blood vessel formation. Some types of cancers form channels that carry blood, but are not actual blood vessels. Drugs that target new blood vessel formation also cannot stop this process, called vasculogeneic mimicry. The realization is that starving tumors by shutting off their blood flow requires that all three mechanisms be addressed.

    It could be vastly more important to measure the net effect of all processes (systems) instead of just individual molecular targets (like VEGF). The cell is a system, an integrated, interacting network of genes, proteins and other cellular constituents that produce functions. You need to analyze the systems’ response to drug treatments, not just one or a few targets or pathways.

    There are many pathways to the altered cellular (forest) function, hence all the different “trees” which correlate in different situations. Improvement can be made by measuring what happens at the end (the effects on the forest), rather than the status of the indiviudal trees.

    VEGF-targeted drugs are poorly-predicted by measuring the preferred target VEGFR. They can be well-predicted by measuring the effect of the drug on the function of live cells. Dr. West had mentioned in a previous posting that for years, physicians have settled on the smallest amount of tumor tissue possible, often with a fine needle aspirate that collects just a few cells, for biopsy analysis.

    He went on to state that we need to use larger bore needles to perform core biopsies or even remove entire lymph nodes, so that we can collect enough live “fresh” tissue to more reliably determine the histologic and molecular features of a cancer. I couldn’t agree more. Imaging technologies cannot substitute for the biologist’s thorough examination of the features of a cancer cell.

    Many of these fine drugs (and Avastin is a miracle drug for the few) cry out for validated clinical biomarkers as pharmacodynamic endpoints and with the ability to measure multiple parameters in cellular screens to help set dosage and select people likely to respond. Many molecular diagnostics approved often have been mostly or totally ineffective at identifying clinical responders to various therapies.

    If you find one or more implicated proteins in a patient’s tumor cells, how do you know if they are functional (is the encoded protein actually produced)? If the protein is produced, is it functional? If the protein is functional, how is it interacting with other functional proteins in the cell?

    All cells exist in a state of dynamic tension in which several internal and external forces work with and against each other. Just detecting an amplified or deleted gene won’t tell you anything about protein interactions. Are you sure that you’ve identified every single protein that might influence sensitivity or resistance to a certain class of drug?

    Assuming you resolve all of the preceeding issues, you’ll never be able to distinguish between susceptibility of the cell to different drugs in the same class. Nor can you tell anything about susceptibility to drug combinations. And what about external facts such as drug uptake into the cell? You’re not going to accomplish this using genetic tests.

    Improving cancer patient diagnosis and treatment through a combination of cellular and gene-based testing will offer predictive insight into the nature of an individual’s particular cancer and enable oncologists to prescribe treatment more in keeping with the heterogeneity of the disease. The biologies are very different and the response to given drugs is very different.

    The major obstacle in controlling cancer drug prices is the widespread inappropriate use of anti-cancer drugs. As the increasing numbers and types of anti-cancer drugs are developed, oncologists become more and more likely to misuse them in their practice. There is seldom a “standard” therapy which has been proven to be superior to any other therapy. What may work for one, may not work for another.

    Literature Citation:

    Eur J Clin Invest 37 (suppl. 1):60, 2007

    Journal of Clinical Oncology, 2006 ASCO Annual Meeting Proceedings Part I. Vol 24, No. 18S (June 20 Supplement), 2006: 17117

    “Cure: Scientific, Social, and Organizational Requirements for the Specific Cure of Cancer” A. Glazier, et al. 2005

  • dmn says:

    As the wife of a recently dignosed pt with”advanced, aggressive, poorly differentiated st3 nsclc I can say that I’m willing to financially bankrupt myself, lose the business we’ve been successful in for 10yrs etc to pursue any and all alternatives to the standardized treatment programs given to us as “best options”. statistically he’s not going to live more than 2yrs whether we treat with chemo/radiation or nothing at all. Why would I try to pursuade him to try something he is so opposed to (chemo) when I as a nurse 20+years have seen the detrimental side effects experienced by my patients, & own relatives. At 57 my husband never expected this diagnosis (we hoped for pinched nerve, angina, gerd etc. & ignore warning signs too long.) I know there are treatment options out there for his non-resectable tumor. I just have to search to try to find alternatives to standard western medicine and hope I can find the answers before we run out of time. StarTrek has been around since I was little, if TV can simulate, you can’t tell me someone somewhere doesn’t have other methods available. His condition has been changing so rapidly, I don’t have time to search every site (esp. with dialup). We’re open to all options except Chemo but I don’t want to chase quackery around either.

  • sunnyside says:

    “But would people be willing to have their families go into debt for a non-curative treatment that would be expected to extend survival by 2-3 months? Is it more the hope that a person will be one of the major beneficiaries that gets many months or even years of benefit, and it’s not possible to put a price tag on hope?”

    I was diagnosed with stage IV NSCLC in March and should also disclose that I am a physician. The simple answer to this question for me is no, I would not put my family into debt for a noncurative treatment that would only be expected to extend my survival by 2-3 months. I haven’t faced that dilemma – my insurance covers my Carbo/Taxol/Avastin with just a $20 visit copay. But the problem with the way you posed the question is that you can’t tell any individual going into treatment what to expect as far as survival. I have high school children at home and two out of the house. My calculations about what I’m willing to subject myself to in trade for any increase in survival are very different than they would be were they not still dependent on me. My calculations also include quality of life as at least as important a risk/benefit calculation as the financial one. I understand that I have an incurable disease and that the purpose of my treatment is to give me more high quality life than I would have without it. I have completed six cycles of chemo and have stayed at work continuously as well as continuing to participate in my children’s activities and travel. I wouldn’t continue on the chemo if I weren’t able to maintain my normal activity level.

    I would, however, have started the chemo even if it were a financial hardship to see what my response would be. I would have quit at any point after 2 cycles with any evidence of disease progression. So I don’t think it’s so much that it’s not possible to put a price tag on hope as it is that expected 2-3 months of extended survival in the population can’t be translated to an expectation for an individual. While I don’t really hope to be a long term survivor, I won’t refuse treatment that makes that a possibility until it is no longer a possibility (which I consider to be disease progression on second line treatment – at that point I’ll switch to best palliative care).

    “is there such a thing as a cancer treatment not being worth it financially?”

    As a former one of those primary care nihilists (I have not practiced internal medicine for 15 years, now limiting myself to occupational medicine), I’ve had to make a pretty big adjustment in my perceptions about lung cancer just to talk about treatment, much less actually do it. I would max myself out as far as borrowing capacity is concerned if it were the best chance to give me prolonged survival and only if long term survival were possible.

  • jaminkw says:

    Well now, we are all very passionate about this subject. I have advanced NSCLC and no insurance. I am at a pretigious cancer center because my oncologist went to bat for me and they let me in. I have been in treatment for ten months. They have been generous in working with me and I am eternally grateful. They are now doing an audit to finalize what they previously said they would do and what we thought was final. My husband and I feel very threatened financially. When I’m really upset I can accuse him of only thinking about the cost of my care. Truth is, I think about it too. We are middle income people who weren’t even middle income most of our 44 years of married life. We’ve worked hard, lived modestly and struggled to provide for our own future. I would not opt for a treatment without a whole lot of guarantees if it meant bankrupting us. The thing with the ongoing treatment for what seems like forever at the outside chance I will be the lucky one, it doesn’t take into account that maybe after initial treatment has done the job, I could be the lucky one without the continued treatment! Sounds arrogant but it’s how I feel.

    Judy in Key West

  • Alien says:

    You people are lucky living in a country where at least there is SOME support systems. I live in a third world country, even here the system MAY help the poor or it may not it just depends. Since I had my savings, I found it dihonest to seek support which otherwise may go to someone without money. THE RESULT SO FAR is that I am not broke yet but give it a year and I will have to sell my house, this may see us through for a few years. But all signs are I am not going to be around for a long time, nice to think so. Cuba, Canada and the UK do take care of their citizens but of late NHS of UK is not the same as used to be before Thatcher came in,

    BUT CANCER IS CANCER, it is always the winner,though it may choose to postpone its victory for a while but one you have it you are done.

    Alien

  • jaminkw says:

    Alien, I am sorry for the struggle we all have in this battle against cancer, and I am certain it is particularly difficult in third world ountries. But you would be mistaken to think the support systems here are sufficient in most cases to compensate for the enormous cost of health care in the U.S. Even with savings, it would be unlikely that most of us could get through six months of chemo treatments, labs, scans etc. Costs for a few months of treatment would be more than many of us make in an entire year. And for most of us to sell our houses would not be the answer because then we would have to rent would could be more costly than staying in a modest home we owned. But what I am most sorry for is that you think because we have cancer we are done. I think that many people in many countries no longer believe having cancer is an automatic death sentence. So we keep going physically, emotionally and financially in the hope that we will live.

    Judy in Key West

  • melissa says:

    Dr. West,

    My husband is only 43. He is at the peak of his career and he loves his job. After being diagnosed with stage IV LC in Nov 2007, he has been through Carbo/Taxol, Tarcevar and radiation to lung and eye. During all these treatment, he goes to work every day. To see him suffer through a lot of pain, difficulty in swallowing, coughing up all night etc. and yet enjoys him life and work only makes me wish there is cure for this. I hate this cost/benefit discussion. My opinion is that we’d try everything we can and if we wait long enough, there will be a miracle drug coming out.

    I really admire you for having this site. It gives me knowledge to ask his doctor the right questions and helping us in decision making. Today I nominated Grace for my company (Liberty Mutual)’s charity donation. If they recognize my nomination, my company will match $0.5 to $1 donation. Needless to say, I will support Grace regardless the company match.

    I can not imagine how on earth you can find time to answer our questions. My guess is that you were born as a saint. Thank you from bottom of my heart.

    Melissa

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