The Lynx Group

The $93,000 Question

September 2010, Vol 1, No 4

Sipuleucel-T (Provenge) and cabazitaxel (Jevtana) have drawn much attention both for being the first new treatments for advanced prostate cancer since docetaxel (Taxotere) was approved in 2004, and for their high costs. As described in Dr Newcomer’s accompanying piece, they will add significantly to the cost of care for prostate cancer patients. Ironically, although $93,000 for a course of sipuleucel-T and $8000 per dose of cabazitaxel seem high, these figures aren’t completely surprising when placed in the context of new therapies that have been approved in recent years for other disease sites.

In many ways, we are victims of our own success. We now talk about cancer as a “chronic disease,” where patients are sequenced through multiple different therapies. With each FDA approval, there is a new “line” of therapy. For example, there have been 6 new agents approved for advanced renal cell cancer since late 2005, of which several cost $8000 to $10,000 per month. This does not include surveillance blood work, supportive care medications, or other treatment-related costs. Therefore, even though we don’t spend the whole $93,000 price tag up front, we can easily approach that with several months.

The survival benefit for each individual treatment is often modest (generally between 2-4 months), but the additive benefits resulting from this “daisy chain” fashion has lead to the significant improvement in survival for many advanced cancers. For example the life expectancy of patients treated with sequential new therapies for advanced colorectal cancer now exceeds 2 years; prior to 1996 there was only 1 active agent and life expectancy for these patients was only about 12 months. As a practicing physician, I know of many patients who have benefited from these treatments; although many have died, I believe that they lived longer than they would have without these new drugs. Many continue to work and care for their families. These are the successes that keep me and other oncologists motivated to continue to take care of patients with incurable diseases.

However, is making available every possible treatment for every patient “worth it?” It was easy when the economy was doing well. However, it’s the $93,000 question that has drawn a great deal more attention as the economy worsens. The current system is terribly broken. It allows well-insured patients access to the most expensive therapies but implicitly rations care to patients who are uninsured or underinsured. Many patients are facing increased cost-sharing for anticancer medications, supportive care drugs, imaging studies, and doctors’ visits. It places patients in the impossible position of having to make complex financial decisions alongside medical ones. Oncologists are trained to counsel patients about risks and benefits, including treatment-associated survival improve ments and toxicities. However, even as we are encouraged to promote “shared decision-making,” physicians are ill prepared to add the “cost and value” dimension to these discussions. Framing these issues in the context of median- and long-term survival rates is nearly impossible. (Im agine asking “Would you spend your child’s college savings for a 15% chance that you’ll be alive in 2 years to see him graduate from high school?”)

As a society, we need to have an uncomfortable discussion about how we will address these issues. Although insured patients rarely face the full cost of care, we all pay for these treatments through taxes and premiums. As long as we have publicly funded insurance and share risk with our colleagues through employer-sponsored commercial insurance plans, these should be shared discussions as well.

Instead of asking an individual what she is willing to pay for care, we should be asking as a society what we are willing to sacrifice to make the newest treatment available. Are we willing to pay more in taxes and premiums? Are we willing to cut coverage for other services? Are we willing to ask investors to accept lower profits as a result of lower prices? Are we willing to ask doctors and patients to go through more bureaucratic hurdles to ensure that these resources are used for those who are most likely to benefit?

I doubt that the United States will go the way of the United Kingdom’s National Health Service, which has made the difficult decision to refuse to adopt certain cancer treatments due to their high cost and modest efficacy. However, there are other things we can do to better define the “value” of the treatments we are prescribing. As discussed in 2 recent editorials,1,2 we need to improve our clinical trial process to identify which drugs have the best chance of helping patients.

In addition, we must do a better job in the postapproval setting of collecting data about the efficacy and toxicity of these new drugs. Although most are approved based on their first- or second-line data, many have broad indications and are often used in patients who have been heavily pretreated. Since only 5% of patients enroll in clinical trials, most patients receive costly and toxic therapy of unknown benefit for which little, if any primary data are collected to further clarify the treatments’ risks and benefits for future patients.

I am curious to see how American insurers and policymakers will address the $93,000 question. While sipuleucel-T may be the most costly example to date, it should be seen as the treatment that has forced this conversation, not as an exception.

References

  1. Young RC. Cancer clinical trials—a chronic but curable crisis. N Engl J Med. 2010;363(4):306-309.
  2. Dilts DM. Early warning: an ailing canary in the mine. J Clin Oncol. 2010;28(24):3799-3800.

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