Category Archives: Health Economics

In an attempt to prevent recurrence of breast cancer, chemotherapy is given after surgery. This is known as adjuvant chemotherapy.

One of the standard adjuvant regimens is CMF (cyclophosphamide, methotrexate, and 5-FU). Compared to other adjuvant regimens the toxicity is moderate but all the drugs are given intravenously. About 15 years ago Roche developed capecitabine (Xeloda) an oral drug that is simply 5FU in oral form. The cost of this drug is several hundred times (yes you read that correctly) that of the intravenous drug but the thought apparently was that the drug would save visits to infusion centers, which are also expensive.

Now, as reported in NEJM there is evidence that the use of capecitabine is inferior to CMF as adjuvant treatment of breast cancer in women over age 65. Unfortunately it’s taken 15 years to find this out.

Medicynical note: This experience is yet another example of why we need to compare treatment regimens. It’s counter intuitive to argue against this notion unless you are a drug company. Or an insecure physician who’s ego can’t deal with another source of information, besides the bias offered by pharmaceutical companies.

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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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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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