Is Personalized Cancer Care Affordable?
Vienna, Austria—“Is personalized cancer care affordable?” asked Richard Sullivan, MD, PhD, Director of Kings Health Partners Institute of Cancer Policy and Global Health in the United Kingdom, in an invited presentation at the 2012 European Society for Medical Oncology Congress.
The short answer he gave was “no,” barring seismic shifts not only in the oncology landscape but also in the larger societal picture. He described 3 trends that will be disastrous for controlling the cost of care.
The first problem is the aging population. By the year 2014, 25% of the population in developed countries will be aged ≥70 years, and Dr Sullivan suggested that the “upper limit may well be over [age] 100.”
Second, there is the disturbing “dependency ratio,” which reflects the ratio of workers to pensioners; this has “plummeted,” because fewer children are being born, and it has “profound effects on the healthcare systems’ ability to deliver affordable care,” he pointed out.
Third, there is no sign of “morbidity compression,” a concept that has been proposed but does not seem to be holding up, that although longevity will increase, the chronic morbidity associated with aging will decrease, and there will be “healthier aging.” Without the realization of morbidity compression, he said, society cannot afford to support longer lifespans.
“New data suggest that in many countries, compression of morbidity is just not happening,” he reported. “Instead, we are seeing increasing frailty and morbidity. Years spent in bad health are being expanded, and that has dramatic effects and is a huge cost burden.”
The Business Model of Medicine Raises Hard Questions
Dr Sullivan then suggested that the “real problem” with the business model of medicine is that “all life has a price,” and therefore there is a “finite value.” This is determined by age, sex, geographic region, and employment, among other factors. This “value of statistical life” defines many things within society, including the amount of effort that is put into producing medicines and technologies, and how much society agrees to spend on healthcare, he said.
The debate over what is driving the cost of healthcare “rages back and forth,” Dr Sullivan added, with some arguing that costs are a result of greater utilization of healthcare resources, and others suggesting that high prices are to blame.
According to Dr Sullivan, 75% of increasing healthcare costs are a result of pricing. “Price is the predominant macro factor within cancer medicine,” he asserted.
There are also cultural issues at play. “Humans are very pro-medicine. We have an embedded psychological drive for new things, and we love consuming medicines,” Dr Sullivan said. “The result is increased spending on cancer drugs and technology. This is big business, and it is increasingly expensive.”
Data from 2007 to 2012 show that although sales are flattening in many therapeutic classes, oncology is undergoing extraordinary growth. The annual growth rate for spending is 10% for targeted agents and even 4% for traditional chemotherapy.
“The money involved in this is quite substantial, and this is just medicine, not biomarkers and other related things,” Dr Sullivan added.
Public Health Concerns
If one accepts that healthcare systems follow a “grain silo” model for capturing the overall economic impact, the system cannot hold, Dr Sullivan predicted.
The hour-glass–shaped “grain silo” model features a wide opening at the top that represents translational medicine, a narrow center that forms the outlet through which the “grain” flows, and a wide base at the bottom that represents the burden of disease. “If you put too much in at the top, or the grain is too big, it jams the outlet,” he said.
At the top, in the translational science bin, there are currently 624 new molecular entities in phase 1 to 3 trials, 412 prephase 1 agents awaiting trials, more than 1300 biomarkers, and an unknown number of technologies.
“Pushing up against this are all things that jam the outlet, including regulatory issues, economic issues, patient numbers, macroeconomics, the dependency ratio, and so forth. Things keep getting stuck,” he said. “We have had to kill off 50% of the pipeline to get things running. The worry is that the outlet is far too narrow for what is going through.”
He added that the “global reality” of cancer is that outside of high-income countries, most patients with cancer present with late-stage disease. Cost-effective surgery and radiotherapy are the mainstays of treatment in many populations, and cancer risk factors are a huge problem.
“In public health terms, personalized medicine, as it currently exists, is almost irrelevant on the global scale,” Dr Sullivan pointed out.
Are Personalized Medicine and Affordable Care Compatible?
“So, are we seeing the death of affordable cancer care with personalized medicine?” Dr Sullivan asked in closing. There are 2 schools of thought.
“One says that personalized medicine will deliver a future affordable care system. We will stratify patients and use less medicine, although it might be more expensive up front. The fatalistic perspective says ‘no,’ that we will have Darwinian selection that is not based on rational choice,” he answered.
“My own concern is that personalized medicine has yet to deliver on
its promises,” Dr Sullivan offered. “Affordable cancer care is about fair cancer care,” and this is not happening, he said, when 62% of personal bankruptcy filings are a result of medical costs, for example. Furthermore, it is well known that putting money into the healthcare system does not, in itself, lead to better outcomes.
“If we are not going to be more intelligent about personalized cancer care,” he predicted, “it will end up looking like a supermodel with a Louis Vuitton handbag: lovely to look at, very expensive, affordable to only a few, and of no real value to society as a whole.”