Signs & Symptoms

Cancer Drug Costs Redux

Several years ago, I had to undergo surgery on my cervical spine due to progressive osteoarthritis that was causing both a sensory and motor neuropathy in my right arm. The procedure, which was performed at a prestigious New York City teaching hospital, took approximately 90 minutes, and the surgeon’s fee (not the entire hospitalization) was $40,000. I’m guessing I was not his only surgery that day. I thought about this because I was recently reading the latest copy of The Cancer Journal, which was devoted to the issue of cancer drug costs. We are all familiar with the term “financial toxicity” as it relates to the high cost of oncology drugs, and the financial burden this places on cancer patients and their families. There were also questions regarding the “value” of novel anti-cancer agents and implications that oncologists don’t clearly explain all of a patient’s options prior to starting a course of therapy, but rather “persuade patients to try numerous lines of treatment with diminishing returns,” a situation that may exist, but which I don’t believe is the norm. Are cancer drugs expensive? Compared to other routine costs that one encounters in daily life, the answer is probably “yes.” But I believe that we must put this assessment in context. Certainly health care, in the United States, is expensive (to wit, the cost of my neck surgery – by the way, the surgeon’s New York City luxury apartment has been featured in Architectural Digest). The United States spent $3.7 trillion on healthcare in 2018; in 2017, the last year for which I could find data, the direct medical cost of cancer care was $105.5 billion. Of this, 52% was spent on out-patient/provider care, 23% on in-patient care and 20% on prescription medications,^* which included not only drugs directed at the cancer itself, but supportive care agents as well, such as pain medications. But even if all prescription drugs were included, 20% of $106 billion is $21 billion, which represents 0.6% of all annual U.S. health costs. There was also mention of pharmaceutical companies “profiteering” from anti-cancer agents in one of the Cancer Journal articles. I found this interesting, particularly in light of the latest listing of companies in the Fortune 500, where there was not a single pharma company within the first 100 companies listed (the first pharma company listed was J&J, at number 104), but where there were several pharmaceutical benefits managers, “big-box” drugstores and insurance companies, including CVS (#13), United Health Care (#15), McKesson (#16), Americare Bergen (#17), CIGNA (#19) and Cardinal Health (#38). Regarding the “value” of novel anti-cancer drugs, we often hear the opinions of insurance companies, pharma companies, even physicians, but rarely do we hear from patients. Palbociclib improves the median progression free survival by 10 months in some patients with HR-positive, HER2-negative advanced or metastatic breast cancer in combination with an aromatase inhibitor or fulvestrant in patients with disease progression following endocrine therapy. Palbociclib has an average wholesale acquisition price of $128,000 per year. Is living an additional 10 months without worsening of cancer worth $128,000? That is a question that is beyond the scope of this article, but I’m willing to guess that there are more than a few breast cancer patients who would answer in the affirmative. The issue, then, is not the cost of anti-cancer drugs per se; it is the cost of healthcare in the U.S., and how that healthcare is paid for and distributed, things that I think we all agree could stand improvement. I therefore think that whenever we discuss the cost and value of cancer drugs in the U.S., it be placed in the larger context of overall healthcare costs and value, which would definitely be worthy of further debate and discussion.

Dunbar’s Number and Cancer Research

Not to sound too ancient, but when I started practicing oncology (I won’t tell you what year, but it was post-platinum but pre-taxane), there were only 23 anti-cancer drugs available (cyclophosphamide, procarbazine, nitrogen mustard, carmustine, lomustine, vincristine, vinblastine, etoposide, mitomycin, cisplatin, bleomycin, 5-FU, methotrexate, doxorubicin, daunorubicin, mitoxantrone, dacarbazine, cytosine arabinoside, tamoxifen, megestrol acetate, diethyl stilbestrol, leuprolide and flutamide) and many had limited indications. In the years 2017, 2018 and 2019, the U.S. FDA approved 39 new chemical entities (new drugs), as well as additional indications for drugs initially approved for other indications. When I started practice, most cancers had one, or perhaps two, recommended regimens. Patients progressing following these treatments had little hope of survival, and clinical trials were not nearly as plentiful as today. The current National Comprehensive Cancer Network guidelines list 6 different agents for HER2+ breast cancers alone and the “holy grail” of treating cancer without cytotoxic therapy has been realized for certain malignancies (e.g., the use of venetoclax and rituximab in relapsed CLL). This is all absolutely wonderful news for patients with cancer; it is impossible to describe the degree of progress that has been made in cancer treatment in the last 40 years. There are now well over 100 different agents approved for the treatment of cancer and its complications and this far exceeds the number of agents for any other medical specialty. Given the current pace of research, these numbers will only continue to increase in the foreseeable future. Robin Dunbar, an evolutionary psychologist, has shown that for any individual, there is a “cognitive limit” of approximately 150 other individuals that can be known, a quantity that has been designated Dunbar’s number. The number of unique cancer therapies/indications already exceeds Dunbar’s number and will no doubt continue to increase. To repeat – this is all fantastic news for patients. But how will we plan development programs in the future when each malignancy, even those segmented by an underlying mutation or biomarker, has 4, 5 or 6 approved agents? Most regulatory authorities only allow enrollment into clinical trials after all approved agents have been exhausted. What sort of response rate can we expect of a new agent after a patient has received 5 or 6 prior therapies? And what is the “cognitive limit” of oncologists for new drugs? Absent a therapy (or combination of therapies) that can provide cure for a particular cancer, we will need to consider how we develop new cancer treatments as we leave Dunbar’s number in the dust.