Thomas J. Smith, MD
Emerging targeted therapies are extending survival in many cancers, but the cost of these new treatments is often high. For example, sipuleucel-T (Provenge, Dendreon) for metastatic castration-resistant prostate cancer costs $93,000 for the full course of three infusions. Ipilimumab (Yervoy, Bristol-Myers Squibb), the first treatment for metastatic melanoma to improve overall survival in more than 10 years, costs $120,000 for four infusions over a span of just three months. Everolimus (Afinitor, Novartis), for renal cell carcinoma and pancreatic cancer, costs $10,000 a month.
Many of these medications are indicated at the final stage of cancer; on average, they extend lifespan by a few months at most. As a result, as new therapies become available in clinical practice, questions about costs versus benefits are increasingly emerging. Among the often difficult questions being asked: Are the survival gains worth the burden on the healthcare system and individual patients? How do we pay for new drugs, diagnostics, and technologies— and who should pay?
Like it or not, economics are driving treatment choices for patients in the real world. Even when a drug is covered by insurance, many patients are not able to afford even the copay. Thus, despite advances in innovation and care, cost is hindering use of new therapies.
To gain perspective on these issues, Targeted Therapy News
spoke with Thomas J. Smith, MD, director of Palliative Medicine at The Sidney Kimmel Comprehensive Cancer Center and professor of Oncology at Johns Hopkins Medical School in Baltimore, Maryland. Smith discussed the rising cost of cancer therapies, the burden of cost, and the cost-benefit analysis of end-of-life care, and will also speak about these issues at the 2012 annual meeting of the American Society of Clinical Oncology (ASCO) in a session titled, “Costs of Cancer Care: Affordability, Access, and Policy.”TTN: How can oncologists stay informed about the best decisions on care alongside their patients in the context of new high-cost targeted therapies?
It is complicated. I think the first question we have to ask ourselves as oncologists is, “Does it work?” Is there a clear-cut improvement in overall survival or disease-free survival, or quality of life that makes it better than other treatments? If the answer to this first question is yes, then the next question is, “How much does it cost and to whom?” And these are really difficult questions because sometimes the cost can be extraordinary to society as a whole but very little to the patient. The patient may only have an annual $1000 copay for a $120,000 new melanoma treatment, for example. In other cases, they may need to pay up to 40% of the cost of treatment. Oncologists need to discuss costs directly with their patients. I have learned to ask my patients, “What is your insurance coverage?” and “How much is this going to cost you?” before having the patient receive a $120,000 bill they cannot pay.
For example, aromatase inhibitors for breast cancer cost $450 a month even though there are three of them on the market and all of them are essentially interchangeable. This gets to an issue of compliance. Some patients simply cannot afford the 20% copay.
Like it or not, economics are driving treatment choices for patients in the real world.
The cost of the end-of-life care is very high for cancer patients. How do oncologists reconcile these costs with providing the best treatment for their patients, while also recognizing whether the quality of life may be more important for a patient with advanced-stage cancer?
Many of us were trained to treat the disease and as long as there is something that can be done, to keep treating as long as it does not make the patient deathly ill. This has worked for our patients for the most part. Sometimes, I think the deathly ill part gets neglected a little bit because we tend to ask less about our patients’ quality of life than we should.What role does palliative care play?
Palliative care was always designed to improve patients’ symptoms and coping, to lessen depression, and to lessen caregiver burden. It is only an interesting sidebar that it results in cost savings. The cost savings are substantial. It could be anywhere from 20% to 50% of the cost in the last month or six months of life that can be reduced. This type of care allows patients to get out of the hospital, where most people don’t want to be.How does this affect our current healthcare spending as a whole?