Is Treating Cancer Worth It?

12 Responses to “Is Treating Cancer Worth It?”

1. Red Baron on July 24th, 2008 3:44 pm

   Even if you forget moral issues like whether spending ‘large’ amounts of money on people who are going to die in a few months is a good use of society’s money or not (I like to call society ‘the collective’), there is still a MAJOR flaw in this logic from an economics standpoint that makes the whole article next to meaningless.

   The flaw centers on a frame of reference issue. Life and markets ‘look forward’ but journalists try to reconstruct by ‘looking backward’. And this difference makes all the difference (a little like Einstein and relativity).

   For you need to remember that a drug researcher or a drug company never actually know whether a new medicine like Nexavar is going to be ‘a cure’ or just ‘a little bit better’ until the drug has been discovered and studied. Consumers might look at the high retail prices and say ‘we can’t afford this’, but that is VERY different than saying ‘but we already developed it and now want to use it because it works’. Most of the high retail prices a consumer pays represent recovery for development costs + profit. Yet the actual cost of producing a drug which is well understood is quite low—in fact often next to nothing.

   The classic example of this might be Prilosec. Remember how it cost many thousands of dollars a year when it first came out so that its use was limited to treating things like Zollinger Ellison syndrome? Yet today the over the counter price is just a few bucks, as that is all it costs to actually make and distribute the drug now that most of the discovery issues related to the drug are known.

   Are the authors suggesting we discover and develop drugs, but once the cost to actually produce these drugs is at its lowest, we still not use them in patients? And if we did this, how do we reimburse the researchers who developed the drug?

   Or are they suggesting that someone else pay for the researchers? If they are, this solves nothing since where does that money come from?

   Or are they saying we should stop the research?

   Or are they saying we should lower development costs? If they are, then there have been lots of people in the drug industry for years that have been saying that in our quest to get it ‘perfect’, we are making it very very expensive.

   Or are they suggesting we stop research, or do ‘less’ of it?

   The way this article frames the rationing issue (which is the same way everyone else seems to frame the rationing issue) is meaningless.

2. Red Baron on July 24th, 2008 4:23 pm

   And when you say… “the fiscal challenge for the payers would be much worse if these expensive drugs resulted in very prolonged survival”

   This is not really true either.

   Remember, the drug company is looking at recovery + profit.

   If they can only get this from a patient in 6 months before they die, they have to front load the cost so to speak. If the drug company can get it over 10 years, costs per month drop dramatically.

   Keeping people alive longer is not necessaily more costly to the system, what matters is what the person who keep alive does with their gift.

   If they remain confined to a nursing home with a feeding tube or spend their remaining years on the golf course in a golden years prachute, then the collective gets no further productive economic activity from the patient, and it is pooer.

   But if the gift of life is given to a person who goes back to work and continues to contribute economically to the collective, keeping someone alive can be a wonderful collective financial investment.

   It is the difficult discussions around these issues that causes this to be “Where even angels fear to tread”.

3. DrRich on July 24th, 2008 5:05 pm

   Red,

   Thanks for your comment.

   My post did not attempt to address the issue of how a robust medical research effort could be maintained within a system of open rationing. It was simply an attempt to say that, under our present system of covert rationing, we have no way of addressing the question equitably.

   Your comment appears to indicate that we can only have true medical progress under our current system (or one like it) – I say this because all the possible alternatives you advance (under your litany of or’s) are bad ones. I disagree both that our current system is healthy for medical research, and that a system of open rationing would necessarily be bad for medical research.

   First, our current system is clearly headed towards demonizing medical research, especially research done by for-profit companies, and is likely some day to severely stifle it if not shut it down. Drugs like Nexavar and Avastin are seen as bad things (because of the cost) developed by bad people (who care only for profit) instead of as remarkable advances that, with enough time and enough work, will lead to affordable and much more effective solutions.

   So that’s one difference between us. You see the current system for conducting medical research as healthy and effective. I see current medical research as reasonably effective (though inefficient), but as being systematically driven down a path that will ultimately lead to its suppression. As I see it, if we don’t move away from covert rationing, covert rationing will act powerfully to stifle the kind of research that leads to expensive therapies, even if those therapies have enormous promise.

   Second, I can imagine (and have described in detail) a healthcare system which openly recognizes limits and which organizes itself in order to minimize the damage such limits do to individuals, and to make sure that the healthcare we do provide is maximally efficient and effective. (Covert rationing, on the other hand, maximizes inefficiency and waste; it must since it inherently must operate under a hidden agenda.) This envisioned system would specifically provide mechanisms for paying for new therapies like Nexavar and Avastin, that is, therapies that represent the first step in some new therapeutic pathway. It will do this because encouraging research that aims to advance diagnostics and treatments would be defined up front as a primary mission of the healthcare system.

   For instance, coverage for new advances could be guaranteed if they: can save the healthcare system money (spend $100 on this product, and you’ll save $120 over the next two years); can save society money (by, say, increasing the probability of returning a patient to productivity for at least a time); represent true innovation (something other than a me-too drug that offers only marginal benefits in a mature product line – both Nexavar and Avastin would fit here as innovative); show promise of moving some aspect of healthcare outside of the healthcare system and into the realm of consumer products (so that it eventually would be paid for like TV sets and cars). Other categories of medical advances that would receive guaranteed coverage could be imagined.

   Further, coverage would also be likely for therapies that measurably improve survival or quality of life. The coverage decisions here would be based on objective, pre-defined cost-benefit methodologies. Treatments that do not quite meet those pre-defined thresholds could be covered up to the threshold, and patients could be given the option of paying the difference themselves.

   In my view, as one who has worked extensively in the biotech industry doing R&D, such parameters for payment would wonderfully focus American entrepreneurs and researchers in a way they are not focused today.

   Again, details of my ideas are available, and I’m sure you will have quibbles should you choose to read them. Anybody would, and the specifics of any such system obviously would require much negotiation and debate, not to mention heartache and pain.

   But please don’t just assume that I haven’t thought about supporting ongoing medical research under open rationing. It is clearly a fundamental issue, and it’s one in which I am heavily invested in my “other” career.

   Finally, it is unfortunate that I cannot address all possible aspects of a question in each and every blog post. I try to limit the subject of my blog posts, such as they are, to one specific, circumscribed point. I am writing a blog and not a treatise. And when I fail at limiting myself I am not being comprehensive, but rather, undisciplined.

   Rich

4. Paul P on July 24th, 2008 5:22 pm

   Short answer: No.

   If a $5,000 a month drug can cure the cancer, then give it for as long as it takes.

   To “gain” months to a year, at those costs, will bankrupt the system eventually. Just as keeping people alive through artificial means, with months in the hospital or elsewhere, when there is NO quality of life, will.

   This country (Americans) can not seem to accept death. We’d better learn to, soon, or we will bankrupt ourselves.

5. Red Baron on July 24th, 2008 9:26 pm

   Rich, I am sorry, you have misunderstood my posting. Having only recently come to your blog, and not having read any of your older posts, I should have put two and two together and realized it was the ‘covert’ aspect of rationing you are were angry at, but I did not We are completely on the same page here.

   I am not suggesting that I prefer our system of covert rationing over a system of open rationing; in fact I prefer just the opposite. Open rationing seems a much ‘fairer’ way of keeping the discussin where it always should have been– a national values discussion.

   And yes, there are definitley some who demonizing ‘for profit research’ (Maggie Mahar comes to mind), but these people have been around since the beginning of time. For profit research remains the primary source of new drug development in countries that openly ration, I am not aware of a national outrage by British citizens at the profit motive of these researchers.

   Research can be focused, but there is also a Black Swan element to the whole thing.

   Paul,

   I agree with your view that IF cure than pay– but pay regardless of what the person does with the gift society has given them? The road to hell is paved with good intentions…

   But my main problem with your statement is your little rider “when there is NO quality of life”…

   What if it is 3 months of quality life, but still VERY expensive to maintain?

   Though I agree getting americans to start a rationing dialogue at this most basic of discussions is still a big improvement over the current national dialogue (which is none).

6. DDx:dx on July 25th, 2008 9:34 am

   If you are interested in the “marginal benefit” in medicine there are some more researched and established examples. For instance, invasive treatment for acute MI(CABG, or Angioplasty…NOT stents) have been shown to save lives in 2 and 4/1000 treated. That is we do 250 angioplasties and 500 CABGs to save ONE patient….Yet the “culture” of medicine is strongly on the side of intervention.
   I’ll bet if you asked most docs they do not know this Number needed to treat. We tend to believe we save every life we treat…And the patients with the scar on the chest and the inguinal hematoma tend to believe they were “saved” too…Something about us humans and “belief”…

7. Red Baron on July 25th, 2008 10:48 am

   DDx:dx Agreed.

   Have you ever looked at the number needed to treat and cost per year of life saved for telemetry?

   Makes cardica transplantation look like a real bargin in comparison.

8. Matt on July 25th, 2008 1:19 pm

   What about the idea that a lot of the scientific research that lays the foundation for these types of discoveries is funded with public money (government grants)? Isn’t there an ethical obligation to ensure that the therapies developed from this knowledge be available to the people that originally footed the bill?

9. Red Baron on July 25th, 2008 4:41 pm

   Matt, you are making a “which came first: the chicken or the egg” argument

   So while the answer to your question is “yes”, still the money that the government uses to pay for research is part of the reason healthcare is so expensive in the first place. The fact you do not recognize this implies you do not see the circular nature of economics.

   For if you ask “where did the government get the money to give to research grants in the first place”? You will of course realize the government got the money by taxing people. And taxing people means those who are taxed have less money to spend on healthcare in the first place vs. had the research never been funded and had they never been taxed in the first place.

   Asking that publicly funded research be made available to patients does not solve the issue of escalating healthcare costs at all. The belief that it does rests on falty assumptions.

   Only rationing solves the problem (i.e not doing the research), or improving producitivity (i.e. doing the same research for less money) solves the problem.

   This blog suggests that we as a collective consciously decide how we are going to ration based on common values we all share, as opposed to letting rationing happen in ways that might run contrary to our collective values.

   … I guess I should ask whether you agree with that description Dr Rich?

10. DrRich on July 27th, 2008 10:40 am

    Red,

    That’s pretty close. Covert rationing is so incredibly destructive to patients, doctors and society that, since rationing is absolutely unavoidable, open rationing - which offers at least a chance at doing the rationing in such a way as to minimize harm to individuals and to spend public healthcare dollars relatively fairly and effectively - has become a far more attractive alternative, as astoundingly difficult and painful as it will be to figure out how best to do it.

    Rich

11. Red Baron on July 27th, 2008 5:08 pm

    Then you and I strongly agree.

    Evolutionary psychologists believe almost all social interactions between two people can be described by a game theory ‘game’ commonly referred to as The Iterated Prisoner’s dilemma.

    These same evolutionary psychologists believe the emergence of societies can similarly be seen as a fractal of the iterated prisoner’s dilemma; a multiplayer version known as The tragedy of the commons.

    At the heart of both the prisoner’s dilemma and the tragedy of the commons, is trust-faith. Evolutionary psychologists believe that trust-faith itself is the very glue that holds the fabric of our society together (odd how close evolutionary scientists get to religion, but that is for another blog…)

    Open rationing engenders trust, making it is easy for all to to see what the rules we have and whether we are following them ‘fairly’. On the other hand covert rationing destroys trust, for reasons I should think are obvious to see.

    When trust is gone… Need I go further?

    You do the collective a great service, I for one say “thank you”.

12. Quiact on January 26th, 2009 11:25 am

    The Innovation of Biologics (Specialty Drugs): How Is Value Defined Regarding Their Use?

    Beginning in the late 1970s, biopharmaceuticals were being researched conceptually for potential creation in at that time in some academic institutions throughout the United States. And it was here that actual researchers in fact conducted basic research to identify new product candidates as they applied a great amount of time and effort fueled by their curiosity of what may be possible. This same protocol and passion is applied with biopharmaceuticals and the companies that create them today as it was then.
    Known also as Red Biotechnology, it is believed that the first biopharmaceutical therapy ever was synthetic insulin called Humulin, which was made by Genetech in 1982, that utilized what is called rDNA technology, which also is used to produce human growth hormones. Later, the rights were sold to Eli Lilly for this insulin product. Yet Genetech was the catalyst and apex of biopharmaceutical growth then as it is now to a large degree. And such companies are truly research-driven. Today, they employ around 1000 scientists to continue their drive to research potential biologics. And with Genentech remains independent, although Roche owns a large portion of this company.
    Biopharmaceuticals are distant and covert and distant relatives of big pharmaceuticals, whose medications are formed by synthetic small molecules, and are carbon based in their design. Due to the lack of innovation and creation of truly unique products in recent years utilizing this method, possibly, large pharmaceutical corporations in particular have become intimate with the innovative biopharmaceutical companies more often now than ever. In fact, large pharmaceutical companies often acquire biopharmaceutical companies that usually are comparatively very small start-up companies often. These large pharmaceutical corporations do this because, along with other reasons, biologics are in fact monopolies due to the undeveloped protocols for biosimiliars, which are the possible copy of what are the generic forms of typical branded pharmaceutical drugs. In addition, biopharmaceutical companies have historically experienced accelerated growth that has proven to be quite lucrative for them. Presently, this biologic industry is an 80 billion or so dollar per year franchise- with roughly 15 percent growth each year with this particular market, it is believed. It has been reported that are about 250 biologics on the market presently, with more to come.
    How do these drugs differ from typical drugs that have been made before this advent of biopharmaceuticals? Unlike the small molecule, synthetic, carbon based pharmaceuticals of yesterday, biopharmaceuticals essentially are larger and very complex modified proteins derived from living biological materials, such as antibodies, hormones, or enzymes.
    One method of these creations is that a transformed host cell is developed to synthesize this protein that is altered and then inserted into a selected cell line. The master cell banks, like fingerprints, are each unique and cannot be accurately duplicated, which is why there are no generic biopharmaceuticals as of yet, as there is no known process to create them. So the altered molecules are then cultured to produce the desired protein for the eventual biopharmaceutical product. These proteins are very complex and are manufactured from living organisms and material chosen for whatever biopharmaceutical that may be desired to be created. It is difficult to identify the clinically active component of biopharmaceutical drugs. So manufacturing biopharmaceuticals clearly is a different and innovative process, and a small manufacturing change could and has raised safety issues of a particular biopharmaceutical in the developing process, as altering the immune system of a potential user of a biologic therapy is risky. Also, it takes about 5 years to manufacture a biopharmaceutical. And each class has a different method of production and alteration of life forms to create what the company intends to develop. Yet overall, their development methods are rather effective, and cost over a billion dollars to bring to market.
    However, there is a risk with biologics themselves, as they alter the immune system of the one receiving biologic therapy intentionally. For about the past 10 years or so, about 25 percent of biologic therapies have had one or more safety-related actions since the time these biologics were approved for marketing. Greater than 10 percent of biologic therapies have black box warnings now with their prescribing information, which indicates a higher level of risk than with other medications. Yet, since the advent of biologics about 30 years ago, the safety of these therapies have been progressively increasing as new therapies are brought to market. Yet the safety issue could be further improved by the FDA increasing their investigation of a biologic agent that is being considered for marketing approval, as well as increased reporting of adverse events after the biologic agent is approved.
    Over 20 biopharmaceutical drugs were approved in 2005, it has been reported, and their growth has tripled compared with what the large pharmaceuticals experienced then. Presently, over 20 biopharmaceutical products are blockbusters by definition, according to others. They are overall very effective treatments for what are viewed as very difficult diseases to manage and treat. This is due to the fact that some biologics target specific etiologies of these diseases, while limiting side effects because of the specific way in which such products work. Yet of the nearly 400 biopharmaceutical companies that are publicly traded, about a third are more or less going broke, it has been reported presently. The industry employs about a quarter of a million people in the united states, it is believed.
    Unlike traditional medications that have been created in the same way for decades, biopharmaceutical companies seek through their research specific disease targets by genetic analysis and then search for a way to manipulate this target in a very specific way to provide superior treatment for such patients. Furthermore, these products are biologically synthesized and manipulated to maximize their efficacy while not crossing into a patient’s bloodstream.
    There are about a dozen different classes or mechanisms of action of biopharmaceuticals that have about a half of dozen different types of uses today. Label alterations for additional disease states occur often as well due to the progressive and novel effectiveness of biopharmaceuticals. Some of these drugs are catalysts for apoptosis of tumor cells. Others may cause angiogenesis to occur to block blood supply to the tumors of cancer patients. Then some biopharmaceuticals have multiple modes of action that benefit certain patient types and their diseases greatly, as with most biopharmaceutical products, the safety and efficacy is evident and reinforced with clinical data and eventual experience with the biopharmaceutical that is chosen to be utilized. And this clinical data is of a different method as well in comparison with what are traditional medications. For example, patients in the clinical trial involving a pharmaceutical are profiled, which allows better interpretation of this clinical data on their products.
    The country of Belgium provides the most biotech products to the biopharmaceutical companies in the United States, and the U.S. leads the world in regards to biopharmaceutical product creation- with more than 70 percent of both revenues and research and development expenditures in this country. Canada is ranked number two in this area, others have said.
    And with the government health care programs who are the largest U.S. payers for pharmaceuticals, Medicare pays 80 percent of the cost of biopharmaceuticals, as many are administered in the doctor’s office, and Medicare part B covers the cost in large part for biologics.
    One issue with biologics is overuse or inappropriate utilization of these therapies, and biopharmaceutical companies are not exempt from federal prescription regulation that exists presently. Amgen, who makes an anemia biologic called Neupogen, recently had to pay a settlement as well as JNJ, who makes an identical drug called Procrit, for rebates and incentives both companies were giving to the users of their products, which were very lucrative benefits, and this resulted in some cases intentional overdosing their patients with these biologics at unreasonable and unnecessary levels, it has been reported. The doctors targeted with these biologics by the makers of these agents are nephrologists and oncologists, as anemia is often seen in their practices for various reasons.
    Another controversy involving biopharmaceuticals is that, while they overall are efficacious and safe, the typical cost of biopharmaceuticals is rather unbelievable, as this cost may approach tens of thousands of dollars per month for some of these biologics. Furthermore, with cancer drugs, they are used together with chemotherapy for their treatment regimens in many treatment centers, so the quality of life comes into question if one considers the devastating side effects of chemo treatment. Another criticism of biopharmaceuticals is that, with cancer patients in particular, they normally provide an extension of their life of only a few months. So there is a debate as to whether the value of biologics justifies their cost.
    Several years ago, I heard a presentation from Roy Vagelos, former CEO of Merck Pharmaceuticals, and heard him as he spoke to others at Washington University in St. Louis about his views on both the pharmaceutical and biologic industries. And during his presentation, he stated something similar regarding the cost of biopharmaceuticals and asked as well about whether or not the value related to the cost of biopharmaceuticals is truly clinically beneficial for such a brief life extension of cancer patients in particular, for the most part. I happen to concur with his premise.
    So there are apparent controversies associated with these unique paradigms and innovations. Yet there are only a few biopharmaceuticals out of many available with debatable benefits with the high price tag. It ends up being what the market will bear for what their makers charge others. Yet the real question is the clinical evidence behind biopharmaceuticals: If a biopharmaceutical stops tumor progression without harming such patients and really extends their lifespan with efficacy that is obvious, then the benefit of such a biological is rather clear. Yet others have argued about the benefits of biological therapies, overall.
    Another difference with biopharmaceuticals is that they are also are additionally regulated by what is called The Public Service Act, and are involved in authorizing the marketing of biopharmaceuticals.
    With many biopharmaceuticals, such as those used to treat cancer, between 70and 80 percent of them are believed to be prescribed off-label, so it will be interesting on how these drugs will be used in such disease states now and in the future, and how they will be regulated as well.
    So the future looks good for this industry, as biologics have tremendous marketing power along with superior therapeutic value with some of the products available, but not all of them. Perhaps they need to improve their absurd cost structure with their agents, as this may improve any negative image others have of the industry now or in the future. A more aggressive approach to bringing to market biosimiliars would enhance the image of this new industry.
    Regardless of the challenges and flaws that exist with biopharmaceuticals and their makers, I’m pleased to see the results and realization of true innovation in pharmacology by taking a different path of drug development. Furthermore, I believe others should behave in a similar manner and be inspired by the biopharmaceutical companies and what they have done and continue to do for the benefit of patients regarding the issue of innovation.
    “The progressive development of man is vitally dependent on invention.” — N. Tesla
    Dan Abshear (what has been written is based upon information and belief)

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