Current Cost of Cancer Drugs Does Not Reflect Value, One Oncologist Suggests
Chicago, IL—According to Leonard B. Saltz, MD, Chief of Gastrointestinal Oncology at Memorial Sloan Kettering Cancer Center, NY, the cost of new cancer drugs is no longer sustainable. Dr Saltz presented “Perspectives on Value” at the Plenary Session of the 2015 American Society of Clinical Oncology meeting.
“Cancer drug prices are not related to the value of the drug, but rather, to what has come before, and what the seller believes the market will bear,” he said. “There’s a tipping point that we have to be willing to search for,” Dr Saltz said.
The cost of treating 1 patient with a new immunotherapy regimen that combines 2 recently approved drugs could reach $1 million. In such a case, the patient’s out-of-pocket cost would be $60,000.
“This year, the premium for a family insurance plan plus out-of-pocket healthcare costs will equal approximately half the average US household income,” Dr Saltz said. “If we carry this to its illogical extreme, by 2028, 100% of household income would be needed to cover insurance premiums plus out-of-pocket costs.”
Two decades ago, the median monthly cost for a new cancer drug was only $1770. That cost rose to $7000 in 2005-2009, and had reached nearly $10,000 by 2010. At its FDA-indicated dose of 2 mg/kg every 3 weeks, the anti–PD-1 drug pembrolizumab (Keytruda) was priced at $16,700 monthly, but higher doses are pushing that cost even higher, he said.
Value and Benefit Are Not the Same
Value and benefit are not the same, Dr Saltz said. “We get enormous benefit from these drugs, but value is not just about benefit. It’s not a direct equation. It’s more a ratio and approximation. The more the benefit, the more the value, but the downside in value is toxicities and cost. We cannot realistically discuss value unless we look at all these components.”
How much will society be willing to pay for 1 year of life gained? In 1995, the acceptable cost of treatment to gain 1 year of life was $54,000; at the end of 2014, that cost had risen to $224,000. “There is no reason to believe this trend won’t continue,” Dr Saltz said.
Checkpoint Inhibitors Can Reach $1 Million per Patient
The most attention-grabbing study presented at the meeting was the efficacy seen with checkpoint inhibitors. The CheckMate 067 study evaluated the new anti–PD-1 drug nivolumab (Opdivo) plus the anti–CTLA-4 agent ipilimumab (Yervoy) in patients with advanced melanoma. This immunotherapy combination resulted in an 11.4-month median progression-free survival (PFS) compared with 6.9 months with nivolumab alone and 2.9 months with ipilimumab alone.
“A median progression-free survival of 11.4 months for combination immunotherapy is truly remarkable for a disease that 5 years ago was thought virtually untreatable,” Dr Saltz said. “As a clinician, I want these drugs and others like them to be available for my patients. As one who worries about how we will make them available and minimize disparities, I have a major problem, and that is that these drugs cost too much.”
How much? “Approximately 4000 times the cost of gold,” according to Dr Saltz. Prices from the first quarter of 2015 show the average per-mg wholesale prices to be $28.78 for nivolumab, $51.79 for pembrolizumab (Keytruda, the other anti–PD-1 agent), and $157.46 for ipilimumab.
Dr Saltz said the treatment cost for a typical patient receiving the CheckMate 067 combination would be $295,566. The use of nivolumab alone would cost $103,220, and ipilimumab alone would cost $158,252.
He projected that applying the total figure to the 589,430 patients dying from metastatic cancer annually, the treatment would cost society $173,881,850,000.
“That’s $174 billion for drugs treating patients with metastatic disease, [with] no adjuvant therapy, for 1 year only,” he said.
Oncologists Must Embrace High-Value, Cost-Effective Care
At this cost, for the highest, most frequently administered dose, a 75-kg patient with melanoma receiving 26 courses of pembrolizumab would generate a treatment cost of $1,009,944.
“This is unsustainable. We must acknowledge that there must be some upper limit to how much we can, as a society, afford to pay to treat each patient with cancer,” Dr Saltz said.
There must be discussions of value and cost among the drug industry, government, patients, and oncologists.
“What can we [oncologists] do?” he asked. “We can embrace our responsibility to deliver high-value, cost-effective care. That means choosing wisely, and choosing not to deliver lower-value, cost-ineffective care.”
Furthermore, “alternative payment strategies must be adopted that do not incentivize around the cost of drugs,” he emphasized.