Medicynic

At ASCO 2011 there were very few studies on cost efficacy, it doesn’t seem to be an issue to researchers funded mainly by pharmaceutical manufacturers. There was however an interesting abstract (6004) which looks at the care provided and outcomes of patients in different socioeconomic groups.

The study was of patients with cancers of the lung, esophagus and pancreas which “account for over 35% of all cancer deaths in the US and a sizable share of cancer costs.”

The researchers from the University of Michigan used the SEER-Medicare data base and examined the effect of socio-economic status on treatment and 2 year survival rates. The authors found:

The lowest SES (socio-economic status) patients were more likely to require urgent or emergent admissions and to be treated at very low volume hospitals and non-teaching hospitals. For all three cancer types, low SES patients were more likely to receive no cancer-directed treatment (e.g., 60% of the lowest SES patients received no treatment for pancreas cancer). Receipt of cancer-directed surgery, chemotherapy, and/or radiation therapy was consistently higher for the highest SES patients, with most patients receiving at one type of treatment and many receiving a combination of treatments.

And concluded:

There is pronounced variation in types of cancer treatment received by different SES groups. Despite receiving more aggressive treatments, higher SES patients do not have improved survival rates.* Reducing variation in treatment strategies may improve healthcare efficiency without changing patient outcomes.

*emphasis by medicynic

Medicynical Note: I’m not sure what more there is to say. We have a primeval, possibly money driven urge, to do all modalities of treatment to patients with bad disease, especially to those with money, insurance or other resources. But we have no impact on the ultimate course of the disease.

This mania is costly. We are using drugs and procedures costing our health care non-system many thousands of dollars a month, uselessly. More careful shepherding of resources and more considered use of treatments would save money (lots) and not impact outcomes adversely.

The American Society of Clinical Oncology meeting finishes and I’m left with a continued disbelief in treatments with limited efficacy costing in the range of $60,000-120,000/year. Patients are not cured; many studies report no survival benefit found as of yet (reports of delays of progression abound); and yet there appears little or no concern whether the advances are affordable by the various insurance schemes or individuals.

Consider the improvement provided by sorafenib compared with sunitinib in Hepatoma ( abstract 4000 at the meeting).

The report noted:

Median OS (overall survival) was 8.1/10.0 mo (HR 1.31 [95% CI: 1.13–1.52], P=0.0019); PFS was 3.6/2.9 mo (HR 1.12 [95% CI: 0.98–1.29], P=0.1386) and TTP (Time to Progression) was 4.1/4.0 mo (HR 1.13 [95% CI: 0.97–1.31], P=0.1785). OS for pts with hepatitis B (Hep B; Su 290/So 288; post hoc analysis) was 7.8/7.9 mo (HR 1.09 [95%CI: 0.9–1.32], P=0.236). In 526/541 pts evaluable for safety, all-causality, grade 3/4 adverse events (AEs) occurred in 82/73% of pts; the most common were thrombocytopenia (19%) and neutropenia (16%) for Su, and skin disorders (21%) for So. Discontinuations due to AEs occurred in 26/23% of pts. Serious AEs were noted in 44/36% of pts, with grade 5 AEs in 18/16%.

Neither drug seems particularly effective but the fact that there was any effect in this difficult cancer is considered an event.

Medicynical Note: Sofafinib costs in the range of $6000/month. It has a benefit of a few months over no treatment and perhaps 2 months over sunitinib, apparently in patients with associated Hep C. Cases of cancer associated with Hep B cases were equally “improved” OS 7.8 and 7.9 months.

It should be noted that when compared with placebo in an earlier study the results were similar, a 2-3 month improvement of overall survival.

Median overall survival was 10.7 months in the sorafenib group and 7.9 months in the placebo group (hazard ratio in the sorafenib group, 0.69; 95% confidence interval, 0.55 to 0.87; P < 0.001).

Dean Baker in the Guardian, notes the obscenity of drug pricing and Senator Sanders’ solution.

We can do better – and Senator Bernie Sanders has proposed a way. He has introduced a bill to create a prize fund that would buy up patents, so that drugs could then be sold at a free market price. Sanders’s bill would appropriate 0.55% of GDP (about $80bn a year, with the economy’s current size) for buying up patents, which would then be placed in the public domain so that any manufacturer could use them at no cost.

Medicynical Note: Unlikely to happen but might put pressure on manufacturers to more reasonably price drugs.

What’s missing from this week’s American Society of Clinical Oncology (ASCO) meeting is analysis of costs. Yesterday we noted exemestane prevented one cancer for 1.1 million dollars spent.

Today we have the story that Avastin is useful to extend the lives of ovarian cancer patients 2.4 months for an estimated $100,000 (cost of one year’s treatment with the drug) plus the expenses of other chemotherapy, doctors visits, and imaging studies–probably another $50,000. Abstract of study here.

The trial enrolled 1,528 women with newly diagnosed ovarian cancer, of whom 90% had advanced disease, Kristensen reported.

They were treated over an 18-week period with a standard chemotherapy regimen of carboplatin (Paraplatin) and paclitaxel (Taxol), with or without bevacizumab.

Patients who were treated with bevacizumab also had maintenance therapy with bevacizumab for another 36 weeks, while those in the other arm were simply observed.

The primary endpoint of the study, he said, is progression-free survival and on that measure, women in the bevacizumab arm had a 13% benefit, which was significant at P=0.039.

For those women, the median time to progression was 19.8 months, compared with 17.4 for those in the control arm, he said.

It was also noted in a quote from the author of the study Gunnar Kristensen that “Overall survival, he said, was less clear”

Medicynical Note: This was a drug company (Roche) sponsored study–Kristensen has a financial relationship with Roche. It’s probably too much to hope that the cost of the intervention would be mentioned, much less factored into the discussion of the results.