Category Archives: Cancer medicine (Oncology)

Gina Kolata’s article in the NY Times (4/24/2009) omits noting the high cost of new approaches to cancer treatment but does highlight the limited progress that has been made.

Over the past 50 years she notes the death rate from cancer has declined only 5% and success in treatment of advanced diseases has been limited.

“With breast cancer, for example, only 20 percent with metastatic disease – cancer that has spread outside the breast, like to bones, brain, lungs or liver – live five years or more, barely changed since the war on cancer began.”

“colorectal cancer , only 10 percent with metastatic disease survive five years. That number, too, has hardly changed over the past four decades. The number has long been about 30 percent for metastatic prostate cancer , and in the single digits for lung cancer.”

But the for drug companies financial results have been spectacular. Drugs, even relatively ineffective ones, may be priced at $100,000/year for the drug alone as noted here.

In the rare instance when a drug is effective the cost is even higher. Gleevec (imitinib), developed largely with tax funds for treatment of chronic myelogenous leukemia, is priced by Novartis in the range of $50,000-$100,000/year (depending on stage of disease and indication). These patients may live 10 years or more at a cost of $500,000 to a million dollars for the drug alone. Is this reasonable? It it the best we can do? Can we afford successful treatments?

The problem with cancer is that it is a genetic disease. As one ages and cells divide mistakes in DNA replication occur. These are random, occurring simply because nature isn’t perfect or because of influence of carcinogens. We can try to control the latter but cancer prevention is not simply a matter of smoking cessation (thought that helps) or diet modification and vitamins (they don’t appear to work). We can try to treat but this ordinarily won’t eradicate the genetic cause.

Medicynical note: The letters to the editor in response to the Kolata article are remarkable. Some quite informed. Some with THE answer: a diet cure , pot, homeopathy, diet to lower the body’s pH, etc.

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Genentech has released preliminary results on the use of Avastin in adjuvant therapy of colon cancer. The treatment failed. (Adjuvant treatment is given to selected patients, generally Dukes 3 colon cancer, after complete resection in hopes of preventing recurrence) Details will be presented at the ASCO meetings in May.

The article in the NY Times notes:

“The existing chemotherapy already keeps about 70 percent of colon cancer patients free of the disease three years after their surgery.”

However, it’s not correct to state that current treatment keeps 70% of people free of cancer. If people who receive treatment were compared to those who did not, the benefit would be about 10%. That is, the recurrence rate would be around 40% for those not treated and 30% for those receiving treatment. That means 30% will recur no matter what we do and 60% wouldn’t recur (in the time period) without therapy.

This article notes the limited efficacy of treatment vs placebo.

“1526 patients with resected B (56%) and C (44%) carcinoma of the colon were enrolled and 1493 were confirmed as eligible. 736 were assigned to the treatment group and 757 to the control group. Fluorouracil/folinic acid significantly reduced mortality by 22% (95% CI 3-38; p = 0.029) and events by 35% (22-46; p < 0.0001), increasing 3-year event-free survival from 62% to 71% and overall survival from 78% to 83%. Compliance with treatment was good; more than 80% of patients completed the planned treatment.”

More recent regimens don’t appear to do much better:

“Oxaliplatin has significant activity when combined with 5-FU-leucovorin in patients with metastatic colorectal cancer. In the 2,246 patients with resected stage II or stage III colon cancer in the MOSAIC study, the toxic effects and efficacy of FOLFOX4 were compared with the same 5-FU-leucovorin regimen without oxaliplatin administered for 6 months.[27] The preliminary results of the study with 37 months of follow-up demonstrated a significant improvement in DFS at 3 years (77.8% vs. 72.9%, P = .01) in favor of FOLFOX4. When reported, there was no difference in overall survival.”

I don’t want to imply that treatment is completely ineffective as some people do not recur after therapy. It is however inefficient in that the great majority of patients receive no benefit.

Using a very expensive drug such as Avastin ($50-100,000 for a course of therapy) for this indication should lead to concerns about cost efficiency and the cost of a QALY (Quality Adjusted life Year). In this case the drug failed but drug companies view adjuvant use as one of the most profitable, and I don’t necessarily mean beneficial, areas and will continue trials.

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An example of the problems with “free” markets in health care–lack of coverage for expensive oral medications used in cancer care. For a number of years, oral medications have been increasingly used in cancer treatment . From Xeloda (oral 5 FU) to Gleevac (imitinab) expensive oral agents have become an integrated into treatment.

Gleevac (imitinab) one of the early targeted drugs (tyrosine kinase inhibitor in Chronic Myelogenous Leukemia) costs anywhere from $40,000/year to $90,000/year depending on dose and indication. Over a lifetime this drug becomes more expensive than most homes. Average families (Median U.S. income about $50,000/year) cannot afford such expense unless insurance provides coverage or they receive free drugs from the company.

Medicare took care of this problem with it’s Part D drug coverage. The issue with Medicare is the donut hole in coverage which requires a yearly $3,000 payment and the 5% copay after the donut payment is completed. In some cases this 5% payment can be considerable as noted in the article.

Most private insurers have lagged in providing this coverage. Oregon has now required insurers to provide equal coverage for IV and oral chemotherapy medication. The rest need more adult supervision.

Another issue is the price demanded by pharmaceutical companies. You and I grant these companies monopoly status for a generation (a patent). This is an industry/government sanctioned imfringement on free “markets”This restraint on open competition is granted theoretically to “encourage development of innovative agents.”

However, drugs priced at more than the yearly income of citizens have become simply unaffordable–by individuals as well as insurers. In other industrialized nations these same medications are priced significantly less. These countries negotiate and otherwise review new drugs and require more appropriate pricing. We need patent reform here as well.

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