Cancer Drugs Offer Hope, but Expense Worries Doctors and Patients

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Cancer Drugs Offer Hope, but Expense Worries Doctors and Patients

New York Times

Ten thousand dollars once seemed a lot to pay for a few months' supply of a

drug.

No more. Avastin. Erbitux. Gleevec. Herceptin. Rituxan. Tarceva. These are

among the first in a wave of new drugs giving hope to millions of cancer

patients by treating the disease in new ways, like blocking the blood

vessels that feed tumors.

But they are all highly expensive, up to $100,000 for a course of treatment

that lasts a few months. That is hundreds of times the cost of older, more

toxic cancer drugs, and several times the annual cost of AIDS drugs, whose

prices caused widespread anger during the 1990's.

And except for Gleevec, a leukemia drug from Novartis that has produced

spectacular results, the new cancer drugs help most patients only

marginally, prolonging life by a few weeks or months.

For now, the high-priced cancer drugs are a relatively small part of overall

medical spending. But some doctors warn that with more new drugs coming, the

use of superexpensive therapies may further fuel the runaway costs of the

health care system.

Dr. Leonard Saltz, a colon cancer specialist at Memorial Sloan-Kettering

Cancer Center in New York, said patients might face rationing of care if

costs continued to rise.

" I don't know how much money there is in the till to pay for all this, but I

have to be worried there isn't enough, " Dr. Saltz said. " There is a limit as

a society to how much we'll be able to spend on each patient. "

Health care economists say the rising costs of the new cancer treatments and

other drugs will force difficult questions on doctors and policy makers.

Should patients be guaranteed access to drugs no matter what their cost? And

should physicians be encouraged to consider cost when they decide on

treatment - something most doctors in this country now say they do not do?

Drug companies say many factors drive the pricing of their drugs, including

the high cost of research and development, complex and expensive

manufacturing processes and the value the drugs provide for patients.

As doctors learn how to use combinations of new drugs in treatment, the

therapies will extend the lives of more and more patients, said Dr.

Desmond-Hellmann, president for product development at Genentech, a

biotechnology company in South San Francisco, Calif. The company makes

several of the new drugs, including Avastin, that are widely considered the

most promising. A year's supply of the drug for an average colon cancer

patient costs $54,000.

" It's a very reasonable thing to ask about the cost of therapies, " Dr.

Hellmann said. " But I just don't want people to lose sight of how meaningful

the changes in treatment are. "

For now, most patients are able to obtain the new drugs, either through

insurance coverage or assistance programs. Lung cancer was diagnosed in

ette Treat, 37, early last year and she was told her life expectancy

was less than two years. She now takes Tarceva, which costs almost $90 a

day, or $31,000 a year.

Ms. Treat, who lives with her husband and two children in Melbourne, Ark.,

has private insurance, which covers 80 percent of Tarceva's cost. But she

stopped working in March after undergoing a double mastectomy when the

cancer spread. She said she could not afford her insurer's $500 monthly

co-payment for Tarceva.

" My husband's the only one working, and we have bills and stuff that we have

to pay, and it takes all he makes for us to make it, " Ms. Treat said. " Five

hundred dollars is a lot to us a month. "

The Patient Advocate Foundation, a nonprofit group based in Newport News,

Va., that helps people obtain medical care, is covering the monthly payment,

Ms. Treat said. " I wouldn't be able to take it if they didn't pay my

co-pay. "

But the foundation covers only a few kinds of cancer and does not directly

assist people who are uninsured, said Beth Darnley, the foundation's chief

program officer. Those patients must apply to Medicaid or to the companies

for discounted drugs.

In some cases, patients are discontinuing treatments or taking other drastic

steps, doctors say.

Dr. Dispenzieri, an oncologist at the Mayo Clinic who specializes in

treating a blood cancer called multiple myeloma, said she avoided discussing

a drug called Thalomid with patients who could not afford it. The drug costs

$25,000 a year and will not be covered by Medicare until next year.

" I don't want them to feel bad, " she said.

If history is any guide, health care professionals say, patients, doctors

and lawmakers will not want to confront questions about how the medical

system should deal with the cost of the new drugs.

" There's not really any incentive in the system to be more rational, " said

Dr. Hornberger, an adjunct clinical professor of medicine at Stanford

University and a practicing physician who studies drug costs.

Policy makers in the United States, unlike those in Britain and some other

countries, do not measure the cost-effectiveness of new drugs, Dr.

Hornberger said. The government does not control drug prices, and Medicare

is prohibited from making coverage decisions based on cost; it must base its

decisions solely on the drugs' performance.

In terms of the cost per life saved, cholesterol-lowering drugs like

Lipitor, which reduce heart attacks and strokes, are probably far more

effective than cancer drugs, Dr. Hornberger said. But cancer is a uniquely

frightening disease, and people will pay almost any price for treatments.

Also, most cancer drugs do not have good substitutes; if a drug works - even

marginally - patients and doctors clamor for it, and insurers have little

choice but to cover it, Dr. Hornberger said.

While some of the new drugs are difficult to make, their prices are

unrelated to their manufacturing costs, said Geoffrey Porges, a

biotechnology analyst at Sanford C. Bernstein & Company. Drug makers charge

what they think the market will accept, he said.

" It's sort of one of those things where everyone looks over their shoulder

at everyone else, says, 'He started it, it wasn't me,' and it builds, " Mr.

Porges said.

Advocacy groups for cancer patients have been mostly silent on drug prices

because pressing drug makers might discourage them from making the

billion-dollar investments necessary to find new drugs.

Doctors also do not want to consider cost, said Dr. Nadler, a

researcher at Harvard Medical School who has studied the attitudes of

oncologists on the issue. In his study, about 80 percent of cancer doctors

said they would prescribe a drug costing up to $70,000 if it would extend a

patient's life just two months longer than the standard treatment.

In fact, the way doctors are reimbursed for cancer drugs gives them an

incentive to prescribe the most expensive treatments. The drugs are

generally given intravenously in a hospital or doctors' office, and Medicare

pays doctors for the cost of the drug plus a slight extra fee to help cover

their overhead. The higher the price of the drug, the greater the extra fee.

As a result of these forces, drug makers have faced only scattered

opposition to the rising prices of new cancer treatments. The upward spiral

started in 1992, when Bristol-Myers Squibb began charging $4,000 a year for

Taxol, a breast cancer treatment that was among the first so-called targeted

drugs, which are aimed at destroying tumors without the side effects of

traditional chemotherapy.

At the time, some lawmakers and patient advocates complained, noting that

Taxol had been invented at taxpayer expense at the National Cancer

Institute. But Bristol held firm.

Then in 1998, Genentech began charging $20,000 a year for Herceptin, another

targeted therapy for breast cancer. The price attracted notice, but little

criticism.

Four years later, Bristol and ImClone Systems began charging as much as

$100,000 a year for Erbitux, a drug for advanced colon cancer. (Because

different patients have different treatment cycles, these prices are

averages, as computed by the companies or financial analysts.)

For drug makers, the high prices have been a boon. Shares of Genentech have

quadrupled in the last two years. Dr. Hellman of Genentech noted that the

company began researching Avastin in 1989, at a time when many scientists

doubted it could work. Genentech spent hundreds of millions of dollars

researching the drug, and decided to build a plant to manufacture it years

before receiving approval to sell Avastin in 2004.

Considering the expense and risk Genentech incurred - as well as the costs

of similar treatment - Avastin is fairly priced, Dr. Hellman said.

" It's a giant breakthrough therapy, " she said. " The value to patients is

very high. "

Cancer drugs will be the fastest-growing part of the drug market for the

next five years, with costs rising 20 percent a year, more than double

overall drug spending, analysts say. Every major drug maker is now investing

heavily in oncology, rushing to capitalize on new research about the way

cancer cells reproduce. Most of the new drugs attack the proteins that help

tumors grow, and most are produced by specially engineered bacteria, unlike

the older drugs which can be chemically synthesized.

Cancer drugs are not the only expensive new treatments; some drugs for

rheumatoid arthritis cost more than $10,000 a year. But the gap between

performance and cost is especially pronounced for the cancer treatments. A

Genentech study of colon cancer patients showed that a combination of

Avastin and standard drug therapy extended the life of the average patient

less than 5 months - to 20.3 months from 15.6 months - compared with the

standard treatment. With the notable exception of Gleevec, from Novartis,

which has been widely praised for prolonging the lives of leukemia patients,

most other drugs show even smaller improvements in survival.

Some oncologists are beginning to question cancer drug prices publicly. Dr.

Saltz of Memorial Sloan-Kettering Cancer Center said doctors must consider

drug cost when they discuss treatments with patients.

" We'd like to feel that it's wrong to put a value on human life and that we

as a society won't do it, " he said, " but we do it every day. "