It's great to hear oncologists talk, not just about the cost of new medicines, but about the fact that their value will increase as we are able to deliver targeted treatments to those of us who will benefit the most.
Medscape recently published a transcript of cancer docs talking about what to do about the price of new drugs. The discussion starts off badly because the issue of price was not raised in the context of value. Nor was the fact considered that the development of targeted treatments for small groups of people with cancer (based on driver mutations) costs as much, if not more, and takes longer than the approval of drugs for cholesterol.
The doctors refer to and laud a recent editorial in Blood claiming that because drugs for chronic myeloid leukemia “affects the lives or health of individuals, just price should prevail because of the moral implications... When commodities are not essential to life or suffering, what the market will bear is appropriate (competition will take care of price), because it is not restrained by ethical considerations. Examples include the price of a Picasso painting, a luxury cruise, a two-week vacation in New York (or 4 weeks in Houston), a Bentley car, a Brioni suit, etc.”
While authors believe a ‘just price’ (translation: price controls or compulsory licensing of patents to the lowest bidder) can achieve more access, the opposite is the case. The consequences of price controls – shortages, black markets, inferior goods – are well documented in housing, agriculture, energy, and medicines. The shortages of oncology drugs we now face were also created by price controls that our merry band of cancer docs seem to support.
And incredibly, a couple of the discussants endorse the UK system of delaying and limiting access of new cancer treatments based on their prices.
Here's David Kerr, Professor of Cancer Medicine from the University of Oxford and former President of the European Society for Medical Oncology talking about rationing... "I was involved with Alan Milburn, who was our Health Secretary. As I become older, I'm becoming more of a public health doc, and I'm starting to understand why, if you make honest, open, transparent decisions about whether we, as a society, can afford these drugs, it is much better than just not talking about it."
It should be noted that 5-year survival rates for most cancers are lower in the UK than in every other country in Europe and much lower than in the United States. That's what happens when you don't use new drugs.
And as for not affording new medicines, it turns out that new, targeted therapies are a bargain. A recent article found that the $13.4 billion it costs to treat CML patients in the US generates $143 billion in economic activity from longer, healthier lives.1 The drug cost of each additional year of disease-free life is about $32,000.2 On a larger scale, the value is even more amazing when we look at just 1% of healthcare spending that is dedicated to new cancer therapies.
Meanwhile, new CML drugs have also reduced the amount time and number of patients that are hospitalized for CML. Since 2001, hospitalizations for CML have declined by nearly 50 percent and the length of stay has fallen 30 percent.4 The percentage of CML patients undergoing blood transfusions, stem cell transplants, and blood biopsies has declined as well. Drugs may make up more of the cost of cancer care but that’s because new medicines eliminate the need to spend money on other, less effective treatments. Targeted treatments mean less trial and error and faster response with less toxicity. If we were treating people with medicines that in Dr. Kerr's view we can afford, more people would be dead and the cost of treating survivors would be higher than it is today.
But the panel stumbles on the right way to increase the value and reduce the cost of new cancer medicines — faster trials, faster approval and faster, fuller access. Using targeted medicines we add years of lives to people with cancer.
Dr. Marshall: I'm always jealous of your lymphoma clinical trials because they are frequently small, enriched, often phase 2 studies that set the standard. I'm jealous of those because I feel like in our big phase 3 randomized studies, we are wasting the standard of treating a bunch of people for nothing. What are some thoughts on how we might further enrich our clinical trial designs to find this value?
Dr. Cheson: We need to identify the important markers and the important therapy. Instead of doing large randomized trials that we are not sure we are going to win, we need to do smaller studies that are hypothesis-generated, biomarker-generated, and things that are really going to work.
Even Dr. Kerr get's it right by the end.
Dr. Kerr: We understand exactly how we are starting to select and stratify; is that going to drive costs down? I have this notion (and I haven't thought it through health economically) that if we start to segment and stratify the population, that 5% of lung cancer patients express marker X and get drug Y. That segmentation, I assume, would drive costs down, but is that correct?
Dr. Cheson: You won't be treating the other 95% with a drug that you know won't work. In that way, it will save money.
Dr. Marshall: Yes. It gets us away from treating everybody for the 20-30% who benefit, so it should save money.
Exactly. And if the doctors would like to learn more about the value of innovation, we encourage them to check out some of the facts we've pulled together.