Category Archives: General Cynicism

Finally, ASCO has a concern about costs? The Need for Comparison Studies

From Forbes:

“But many companies seem to be maximizing cancer profit instead. Big drug companies are making big money off smaller and smaller improvements in cancer care. Newfangled cancer drugs can cost $50,000 a year, and that doesn’t mean they will add a year to the patient’s life–you might spend $50,000 for a year and extend the patient’s life by only weeks.”

Regarding Avastin:

“The hope was that further studies of Avastin in other types of cancer or in earlier stages of the disease would show even greater survival benefits. But they haven’t. In several breast-cancer trials–including a new one being presented at the meeting this weekend–Avastin slowed the progression of disease but did not extend patient survival at all. But doctors still use the drug in treating breast cancer because they figure it helps symptoms, even if patients don’t live longer. Avastin costs up to $55,000 a year.”

More:

“Roche is also combining other expensive drugs with Avastin. One study at the meeting showed that adding Tarceva……. delayed by one month the median time it takes lung tumors to grow. “

Medicynical note: ONE MONTH delay for $50,000. Terrific.

Where is the value? Meanwhile the drumbeat of studies showing very limited improvement but very high costs continues.

Also regarding Avastin:

“Avastin failed to prevent colon cancer from recurring after surgery. In the first year of treatment, more patients who got Avastin remained free of detectable cancer. But after a year, the drug was stopped, and by the end of the study, the apparent initial benefit had faded completely.”

In fact most people who receive drugs after surgery have no risk at all for recurrence. For those with what’s called Duke’s C disease the risk of recurrence is about 35-40%. Treatment with chemotherapy with or without Avasatin decreases the risk of recurrence by 15%. That means 20-25% recur no matter what we do. That also means that around 80% of people receiving these drugs get no benefit at all from chemo (the 60% without risk of recurrence and the 20% who recur no matter what we do).

The costs of these type treatments are astronomical. The drug company’s hopes of having $50,000/year drugs used on all patients are deal busters. I can’t think of a better poster child for comparison studies than those cited above.

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Comparison Study of Taxanes (Taxotere) in Early Breast Cancer Shows no Survival Benefit

It’s fascinating to consider the reasons why anyone opposes the concept of comparison studies to determine the benefit of a treatment. In cancer treatments are extremely expensive, and toxic. Launching patients into therapy without considering the benefit and costs is reckless.

In the May 16th Lancet a study showed no survival improvement when Taxotere was added to standard anthracycline (Epirubicin in this case) adjuvant chemotherapy (the TACT trial).

“At a median follow-up of 62 months, 75.6% of patients who received docetaxel plus anthracycline chemotherapy remained disease free, compared with 74.3% who did not receive docetaxel. The proportion of patients who reported any acute grade 3 or 4 adverse event was significantly greater among patients who received docetaxel.”

But it does add to toxicity:

“The proportion of patients reporting any acute grade 3 or 4 toxicity that occurred during treatment and up to 30 days afterward was significantly greater among those receiving docetaxel.”

The authors do point out that there may be subgroups who benefit. But given the cost and toxicity, adding a Taxane to standard chemotherapy needs further study and verification of efficacy.

Comparing treatments is part of the scientific method. Using this information to inform treatment options is rational medicine and should be encouraged.

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It’s the Money

Fascinating article in The New Yorker (June 1, 2009) on the variations in health care costs. Atul Gawande visits one of the the most expensive Health Care Markets, McAllen Texas, and looks at the reasons.

No surprises here, but nice documentation and explanation of the issues.

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A Week of Cancer News–Be Cynical!!

The American Cancer Society leads off the week with the good news that cancer deaths are continuing their slow decline. The data from 2006 attributes most of the improvement to smoking cessation and earlier diagnosis (particularly in colon cancer). We can expect to inundated with more cancer news from the ASCO (American Society of Clinical Oncology) starting this weekend–watch out for the hype and overstatements!

“The new rate shows 181 cancer deaths per 100,000 people. That was down from about 184 in 2005.”

“The CDC recently reported death rates fell for:

• Lung and trachea cancers, from 54 deaths per 100,000 in 2005 to 51.5 in 2006.

• Colorectal cancers, from 18 to 17 per 100,000.

• Breast cancer, from 27 to 23.5 per 100,000.”

It’s wonderful that fewer people are dying but it should be noted that the most effective intervention was the cheapest–prevention. By having fewer smokers in our population there were few people with lung and related cancers.

Early diagnosis also is an effective intervention. Much of the improvement in outcomes of such diseases as colon, breast and prostate cancer have nothing to do with outrageously expensive treatments but rather are due to early diagnosis and treatment because of aggressive screening for the disease–yes I know prostate screening is somewhat controversial but deaths from prostate cancer have declined since we started screening in the early 90’s.

Treatment is least effective means of extending life. Yes there are successes, such as leukemia, some lymphomas, and testicular cancer. But the survival improvement from aggressive treatment of most advanced cancers has been stagnant for 30 years. Whether new $100,000/year drugs will change this has yet to be proven–so far the data casts doubt on the cost-efficacy, and utility of such expensive treatments.

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Miami’s Health Care Costs: What Happened to Supply and Demand?

Medicine’s costs confound economists. Classical economic theory (I’m not an economist, correct me if I’m misinterpreting) would have you believe that as supply increases demand is met and prices stabilize. In health care as supply increases, demand increases and prices increase. Health care is simply not a reasoned rational system.

Consider Miami: (Time, May 20,2009)

“the 2008 average private-provider costs for a Miami family of four – $20,282 – as the highest among the 14 major U.S. cities it studied, adding that more than 40% of that amount came out of Miamians’ own pockets.”

“Miami’s inordinate health-care outlay – 20% more than the national average – “is not a pretty picture,””

“That’s especially true since Miami-Dade County also has one of the country’s lowest median incomes ($43,495).”

“”South Florida has an “excess capacity of health-care providers and institutions,” Quick notes. And to make sure they all get a piece of the action, they’ve created a wasteful and ill-coordinated system of health-care redundancies, from unnecessary MRIs to inpatient treatment that too often could have been cheaper outpatient treatment. Miami-Dade, for example, has one of the nation’s highest hospital readmission rates – and more MRI machines than Canada.” (Medicynical emphasis)

Medicynical Note: For-profit medicine is simply for profit. In Miami, efficiency and even the patient’s welfare comes second. Can we learn from Miami?

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Conflicts of Interest:Medtronics and Infuse

Conflicts of interest continue to bedevil medical information.

I just received my Amgen sponsored American Society of Clinical Oncology education booklet and at the meetings later this month there will be all manner of company sponsored events. Many of the speakers will have noted their paid employee/consultant status for sponsoring companies.

This from the NY Times suggests that our system of research support and clinicians on the payroll of drug companies has problems.

“A former surgeon at Walter Reed Army Medical Center, who is a paid consultant for a medical company, published a study that made false claims and overstated the benefits”

“reported that a bone-growth product sold by Medtronic Inc.had much higher success in healing the shattered legs of wounded soldiersat Walter Reed than other doctors there had experienced,”

A former Walter Reed colleague, Dr. David W. Polly Jr., who is also a Medtronic consultant, (Medicynical emphasis) said he believed that Dr. Kuklo’s data was “strong””

“The results reported by Dr. Kuklo in his Infuse study “suggested a much higher efficacy of the product being researched in the article than is supported by the experience of the purported co-authors,”

Medicynical note: What’s a medicynic to do? View company sponsored studies with suspicion? Disregard all company sponored drug studies? Look for studies not tainted by conflicts of interest? Hope that in the future comparison studies of efficacy (opposed by drug companies) clarify the benefits and risk of various treatments?

Come to think of it, why in the world would companies dedicated to knowledge and the improvement of medical outcomes oppose studies of efficacy?

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Health Care Reform–How about more detail?

As the NY Times notes it will be difficult to reach the cost cutting goals offered by doctors, hospitals, drug makers and insurance companies. ($2 trillion in cost reductions over 10 years)

Medicynic didn’t hear that drug companies were cutting prices rather they volunteered to decrease the rate of increase. Huh? If your drug costs more than you car, or more than your salary such cost cutting will have little impact. Nor did they come out and support the notion that comparison of different approaches would improve care and cut costs.

Medicynic didn’t hear insurance executives volunteer to match the administrative efficiency of other industrialized nation’s insurance plans. Rather they promised to “end certain underwriting practices, like refusing to cover individuals with pre-existing conditions or charging women higher rates than men.”

According to Mckinsey we spend in the range of 30% of health care expenditures on administration. This is nearly $500 per capita, “five times the average level across 13 other countries.”

Medicynic didn’t hear hospitals promise efficiency and cost consciousness. There was nothing noted about geographical differences in costs and utilization but hopefully that will be on the table.

Medicynic, a retired physician, has great sympathy for physicians. They are part of the problem but an essential part of the solution as they control health care resource usage. Unfortunately, in the past, physician fees have been the simplest way to cut costs and many have been unfairly squeezed by previous cost containment efforts. Seeing patients at a loss as primary care physicians do for Medicare and Medicaid patients distorts the fee system–they need to make more elsewhere in the system to compensate. A system that pays more for procedures encourages over-usage.

Physicians have traditionally not considered cost when recommending therapy. This obviously needs to change and comparison studies offer the best way to evaluate cost efficacy.

What I saw was a photo-op, what I heard was rhetoric without commitment; a NIMBY- like approach that is not likely to crowd any of the participants bottom line–except, I would guess, physicians.

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Fee for Service–Part of the problem

We have perverse incentives that increase utilization and health care costs. Consider this:

“Millions of patients each year leave the hospital only to return within weeks or months for lack of proper follow-up care.”

“In fact, because insurers typically pay hospitals to treat patients – not to keep them away by keeping them healthy – hospitals can actually lose money by providing better care. Empty beds mean lost revenue.”

The question is how to align incentives to encourage prevention, efficiency and quality care.

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Swine Flu–Walking and Chewing Gum

  • Thus far the swine flu epidemic has been manageable. 42 deaths in Mexico, two in the U.S., but mostly a reasonably mild disease for the great majority of those affected. Cases will continue but for now as the flu season winds down the epidemic seems manageable. From the WHO:

“23 countries have officially reported 2099 cases of influenza A(H1N1) infection.”

“Mexico has reported 1112 laboratory confirmed human cases of infection, including 42 deaths. The United States has reported 642 laboratory confirmed human cases, including two deaths.”

“The following countries have reported laboratory confirmed cases with no deaths – Austria (1), Canada (201), China, Hong Kong Special Administrative Region (1), Colombia (1), Costa Rica (1), Denmark (1), El Salvador (2), France (5), Germany (9), Guatemala (1), Ireland (1), Israel (4), Italy (5), Netherlands (1), New Zealand (5), Portugal (1), Republic of Korea (2), Spain (73), Sweden (1), Switzerland (1) and the United Kingdom (28).”

In the 1918 epidemic there were episodes of relatively minor disease that were later followed by periods of very virulent disease with explosive spread. The disease altered evolved or perhaps creationed itself (see this) into more dangerous forms which caused a rapidly progressing severe illness, killing millions. This could still happen.

We have some time to develop a vaccine and strategies for more severe disease should they occur. This from Science, May 1:

“Early on, CDC began to brew a “seed” strain for a possible vaccine against swine H1N1, and by 27 April the World Health Organization in Geneva, Switzerland, was already talking to vaccine manufacturers. One key problem is that the world’s influenza vaccine production capacity-which still relies on growing the vaccine virus in chicken eggs-is limited to some 400 million vaccine doses a year and is impossible to expand quickly. Manufacturing swine flu vaccine would thus come at the expense of seasonal vaccine production, says retired pharma executive and flu vaccine expert David Fedson, and might lead to higher mortality and morbidity from the three seasonal strains.For now, WHO says manufacturers should continue preparing vaccine for the 2009-10 flu season. But that could change if swineflu proves particularly severe. “We’re in a casino now, and we’re placing our bets,” says Fedson.”

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Health Savings Accounts–Where are the Savings?

  1. David Ignatius notes:

“He found that for the 53 percent of households that hold at least one retirement account, the median combined balance was a mere $45,000.”

“Hold on, you say, that figure includes some younger workers who haven’t started saving in earnest yet. Okay, for households headed by persons between the ages of 55 and 64, the median value of all retirement accounts was just $100,000. Purcell noted that for a 65-year-old man retiring last month, that $100,000 would buy an annuity that would pay a paltry $700 a month for life, based on current interest rates.”

This in the generation that has lived through what is arguably the most prosperous era of our country’s history.

Meanwhile:

“Fidelity Investments says a 65-year-old couple retiring in 2008 will need approximately $225,000 to cover medical costs in retirement. That doesn’t even include over-the-counter medications, most dental services, and long-term care. The Employee Benefit Research Institute figures a married couple will need a staggering $305,000, just to have a 90 percent chance of being able to pay for all out-of-pocket retirement health expenses (the money could be paid in part out of retirement income, however.)”

Medicynical Note: Proponents of HSA’s (Health Savings Accounts) and other high deductible health insurance schemes say paying for health care is easy. Simply have people use health savings accounts to put aside money for the times when they need it. The problem is that during the most financially remunerative era in our history savings of any type didn’t occur. Moreover, the health of our economy depended on low savings rates to spur consumption.

Something’s wrong here. HSA’s and such engage in magical thinking rather than serious problem solving. They are recipes for disaster. We need to find better ways to control health costs and pay for them.

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