Category Archives: Cancer medicine (Oncology)

No such thing as Cost Effectiveness in U.S. medicine

Medicare has bowed to industry pressure and expanded the use of non FDA approved treatments for cancer. That means very expensive medications with little evidence of effectiveness will be used to treat cancers.

As noted in the article:

“One of the many drugs whose use is likely to expand is the Eli Lilly product Gemzar, which costs $2,500 to $5,000 a month. The F.D.A. has approved it to treat only four types of cancer. But the new rules will virtually guarantee that Medicare will pay for its use for about a dozen other cancers, including advanced cervical cancer – even though the evidence supporting Gemzar for that use is “inconclusive,” according to one of the reference guides Medicare will now be consulting.”

“Under the new rules, Avastin (medicynical note: one of the most expensive medication on the market at $10,000/month) will be routinely covered for ovarian cancer – as will at least some other off-label uses, including for brain and kidney cancer.”

“The new policy, which took effect in November, makes it much easier to get even questionable treatments paid for, critics of the changes say. Medicare is providing “carte blanche in treatment for cancers,” said Steven Findlay, a health policy analyst for Consumers Union. He said overly expansive coverage encourages doctors to use patients as guinea pigs for unproved therapies.”

Medicare has decided that cost effectiveness and value is not a consideration in cancer treatment. Without such analysis any system of health care is a goner.

We need a non-biased organization to review the effectiveness of medications. This evaluation would factor in such issues as whether the drug works for the indication, cost effectiveness and the value to the patient and health care system.

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Cancer Incidence decreases, Survival Improves

It’s wonderful to see benefits of public health interventions reflected in cancer statistics and outcomes.

“Cancer diagnosis rates decreased by an average of 0.8 percent each year from 1999 to 2005”

“The data may point to a real decline in the occurrence of some types of cancer, experts said. Alternatively, the decline may reflect inconsistent screening practices, causing some cancers that used to be detected to now go undiagnosed.”

“Breast Cancer incidence rates decreased by 2.2 percent annually from 1999 to 2005” Medicynical note: likely due to decrease in use of estrogen hormone replacement.

“The incidence of prostate cancer declined by 4.4 percent a year from 2001 to 2005, after annual increases of 2.1 percent a year for several years” Medicynical note: This may be a screening artifact.

“The incidence of lung cancer has been declining among men for many years but rising among women, though the increase is slowing, according to the report.”

“Women, unfortunately, got hooked on the smoking habit in the ’60s and ’70s,” Dr. Eheman said, “so there was a larger increase in smoking later on in time, and the prevention of smoking has been slower. The decrease in lung cancer that we hope will occur has not been happening yet.” Medicynical Note: The decline in lung cancer is almost certainly due to smoking cessation programs which seem to have been more effective amongst men than women.

There was a decline in death rates as well:

“Death rates from cancer fell an average of 1.8 percent each year from 2002 to 2005, according to the new report. Although last year’s report said death rates dropped an average of 2.1 percent each year from 2002 to 2004, a modest 1 percent decline in 2005 lowered the average percentage for the period.” Medicynical note: This death rate decline is almost entirely due to improved disease screening and early diagnosis. The earlier the diagnosis the better the outcome.

However, PSA testing has problems with both sensitivity and specificity. Colon cancer screening seems best done with colonoscopy which is labor intensive and very costly. To further improve we’ll need to develop screening technology that’s less costly more sensitive and more specific.

Treatment may contribute to the improvement but it’s benefit is small, and an order of magnitude more expensive than the prevention and early diagnosis strategy.

Other articles reporting these findings in the media point out the decline in government research funding over the past several years and make a plea for more government spending on medical research.

Medicynic certainly supports such funding but would point out that it’s been common practice to allow patenting of government funded research for the benefit of private companies, individual researchers, and research institutions. These patents allow monopoly pricing of medical advances for a generation. Such misuse of public funds needs to be stopped either by not allowing patenting of government funded advances which would encourage more active price competition and/or enforcing the reasonably pricing provision of Dole-Bayh legislation which facilitated the patenting of government sponsored advances.

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Wide Variation in cost of Treating Colon Cancer

This article in the American Journal of Managed Care only tells half the story. It reports on the costs of chemotherapy for colon cancer using conventional chemotherapeutic agents. As reported common regimens costs are:

Total Cost of 6 Cycles of Commonly Prescribed Treatment Regimens

Chemotherapy Regimen Total Cost of Treatment ($)
5FU/LV (5-flurouracil plus leucovorin) 1,028
IFL/FOLFIRI (flurouracil/leucovorin/irinotecan) 38,027
FOLFOX (fluorouracil/leucovorin/oxaliplatin) 17,584
Irinotecan 25,287
CapeOx (capcitebine/irinotecan/oxaliplatin) 34,744
Oxaliplatin 11,593

Part of the wider variation in cost is the need for leukocyte stimulating factor (GCSF) and erythropoietin with the more aggressive regimens. Given the large difference in cost to the system one wonders why a historical comparison of the effectiveness of the various regimens was not included.

The study was completed in 2005 and the cost variation may be worse now:

“This variation is likely to be even bigger now that monoclonal antibodies, such as cetuximab (Erbitux) and bevacizumab (Avastin), have been accepted as standard therapies to be added onto chemotherapy regimens. The study finished at the end of 2005, and so did not assess the impact of these new products, Dr. Lyman explained. It focused on chemotherapy regimens and found enormous variations in cost. “As bad as it looked then,” Dr. Lyman commented in an interview, “I would guess it is even worse now.”

Cetuximab and bevacizumab may increase costs by as much as $10,000/month and only improve the outcome by a modest amount.

The larger question is whether physicians and institutions should factor in cost to the treatment equation. It’s been our practice to ignore cost when considering treatment alternatives but as the expenditures for health care increase exponentially it may be time to consider another approach.

It is difficult for individual physicians to do all the work on this. In UK there is an agency, the Nation Institute for Health and Clinical Excellence (NICE), that produces studies and make recommendations to their National Health Service. A similar non-biased source of cost/effectness evaluation in our system should be welcomed by all practitioners. For what it’s worth the FDA is prohibited from including cost in their evaluations of new drugs.

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What Tony Snow’s death tells us about Cancer therapy today

Snow presumably had access to the latest and best treatments for colon cancer.  Yet he died just three years from diagnosis.  His disease was apparently localized disease at diagnosis.  He received adjuvent therapy to prevent recurrence.  It failed as it does in about 1/3 of patients so treated,  and his cancer recurred with metastatic disease just over a year ago.

You may hear all manner of propaganda about new advances from big Pharma, new drug regimens,  miracle biologic agents that cost thousands of dollars a month, and improvements of survival.   You need to remember however that the advances improve survival minimally (in advanced disease about two months) at great financial cost.

The lesson if there is one is that the best approach is prevention (for those cancers so amenable) and early diagnosis.  Colonoscopy should be a part of health maintenance for everyone, particularly if there is a family history of colon cancer.