The impact of staggering increases in the cost of individual antineoplastic agents for patients and the overall healthcare system cannot be overstated, and there appears to be no realistic solution to the current dilemma that is acceptable to the parties involved in this ongoing debate.
Maurie Markman, MD
The impact of staggering increases in the cost of individual antineoplastic agents for patients and the overall healthcare system cannot be overstated, and there appears to be no realistic solution to the current dilemma that is acceptable to the parties involved in this ongoing debate. The stakeholders include patients and their families, governmental and third-party payers, healthcare regulators and economists, local and national political leaders, investors, individual providers and hospitals, medical organizations, healthcare systems, and manufacturers and developers of products and devices.
Unfortunately, the generally accepted principles of a free-market economy that have served to effectively control or reduce the costs of products and services in multiple areas have been distressingly ineffective in the arena of healthcare. Consider, for example, a recent report that described changes in the cost of novel antineoplastic agents over time following their regulatory approval and launch in the marketplace.1 Although one might have assumed that increased competition from new products and expanded use due to recognized additional clinical indications would have reduced the prices of the drugs for hospitals, providers, or patients, the opposite has been observed. After an average follow-up of 8 years, the mean change in the cost of all 24 patented injectable anticancer drugs examined in this report was more than 25% higher (18% after adjustment for inflation).
As the cost of cancer treatment continues its relentless upward trajectory, one rational approach to help deal with this situation would be to focus on the prevention of malignant disease and thereby avoid the costs associated with caring for patients with cancer. Thus, cancer prevention should be viewed both as a relevant goal to favorably affect the welfare of individuals and a legitimate topic within the domain of healthcare economics.
One approach to cancer prevention that would have an impact as a long-term cost-reduction strategy is vaccination against the human papillomavirus (HPV). Notably, widespread public acceptance of HPV vaccination has been less than optimal despite overwhelming scientific evidence for its effectiveness and safety (FIGURE 1).2 Why did this happen, what can be done to correct these deficiencies so that the public health benefits can be achieved, and how might such a situation be prevented as other evidence-based cancer prevention strategies are considered for implementation?
The foundational role of HPV in the development of essentially all cases of cervix cancer, other squamous cell gynecologic malignancies, and an increasing percentage of head and neck cancers is well established and not open to rational scientific debate (FIGURE 2).3,4 Further, evidence supporting the clinical utility of HPV vaccination in preventing persistent HPV infection and reducing HPVassociated precancerous gynecologic abnormalities is extremely solid, and reports of meaningful short-term or long-term adverse effects are preciously limited.
What remains absent from the current discussion are definitive data demonstrating a reduction in cancer-related morbidity and mortality resulting from the introduction of a population-based HPV vaccine strategy. Of course, this is a critical issue with all cancer prevention strategies. Since clinically evident malignancies develop years, perhaps decades, following exposure to recognized carcinogens (eg, cigarette smoke), if one mandates definitive proof of this ultimate outcome before establishing the strategy, the desired state may never occur, would be seriously delayed, or would result in countless unnecessary deaths before the evidence is finally accepted.
An additional concern with cancer prevention strategies that has been painfully evident in the HPV debate are issues surrounding the approach that have nothing to do with the goal of preventing cancer morbidity and mortality. HPV is transmitted by sexual contact and acknowledging this fundamental fact requires discussing a topic that is fraught with considerable angst among many in our society. Data regarding the stunning incidence of HPV infection within adolescents and young adults in the United States apparently have little impact on many parents, whose refrain continues to be “this will not happen to my child.” Unfortunately, stated concerns that such beliefs may negatively affect a child’s future health have not been terribly successful in improving vaccination rates.
Therefore, the cancer research community must develop more effective strategies to engage parents and the clinicians who care for adolescents and younger adults but who are unlikely to be professionally exposed to the ravages of adult cancers with the aim of enhancing the willingness of those responsible for the child’s welfare to be open to discussing cancer prevention vaccination strategies. In addition, one must also recognize that many individuals are concerned with mandates that appear to restrict individual liberties. Again, the goal in this setting must be to convince parents and others of the fundamental value of vaccination to the welfare of their children by reducing the risk of preventable cancers.
Finally, to engage local and governmental healthcare planners who are constantly exposed to multiple requests for increased funding and higher prioritization of specific initiatives, it will be imperative that the longer term benefits of cancer prevention, particularly with such robust strategies as HPV vaccination, are clearly articulated—even if this requires the development of models today, in the absence of definitive evidence of a reduction in cancer, showing that such strategies can favorably impact cancer-related healthcare costs.