Saturday, October 26, 2013

No good answer...

One of the manifold reasons why I haven't been posting much at all is trying to support a close friend with cancer treatments (esophageal). The outlook is problematic and I am deeply worried.

Suddenly as well, some information I had considered in abstract becomes more difficult to judge as well - for example, the cost of cancer drugs vs. their efficacy.
No one knew the price of Zaltrap at that point, but Leonard Saltz, who heads the gastrointestinal oncology group at Memorial Sloan-Kettering Cancer Center, had a sense of what was coming. Zaltrap’s effectiveness, in his opinion, was almost identical to that of Avastin, an FDA-approved cancer drug that had also been targeted at that same patient population. Several weeks earlier, Saltz had traveled to Chicago to inflict a little premonitory sticker shock on his medical colleagues. He reviewed the recent clinical results of both Zaltrap and Avastin when used as a “second line” treatment, after initial treatment had failed. As Saltz reminded the other oncologists, Avastin was modestly effective as a second-line treatment—it extended median overall survival by 42 days, the same as Zaltrap—but it cost about $5,000 a month and, like Zaltrap, would have to be taken for many months to achieve that modest clinical benefit. The overall cost was so high that Saltz devoted the end of his talk to a back-of-the-envelope calculation, delivered via PowerPoint, that recast the question in terms of health-care costs: If you extended the 42 days survival to a year, “what is the cost of Avastin for one year of human life saved?”
The answer was astounding, even to doctors who have grown inured to the zero-gravity economics of cancer pharmaceuticals. As Saltz worked his way through slide 73 of 78, he arrived at the bottom line: $303,000.
“Now, that’s essentially the cost of the bare-bones drug,” Saltz later explained to me in his office at Sloan-Kettering. “It’s parts, not labor. No money for doctors; no money for nurses; no money for pharmacists; no money for real estate, heat, and lights; no money for the needles, the IV tubing, the IV fluids, the anti-nausea medicines, the other chemotherapies that are given, because Avastin doesn’t do anything by itself. It has to be given with other drugs … I want to emphasize it’s not that we can have a year of life saved for $303,000. That’s probably less than half of what the actual cost would be when you factor in everything.” Zaltrap, he figured, was probably going to be in the same range.
Saltz’s message was not entirely unexpected. He has been warning about the danger of rising drug prices, to patients and to the health-care system in general, for the last decade. Having made this point to his colleagues, Saltz packed up his computer, took the next flight back to New York, and, after the FDA approved Zaltrap in early August, began to prepare—“not with great enthusiasm,” he conceded—the Zaltrap presentation he would deliver to the hospital committee responsible for approving any new drugs for Sloan-­Kettering’s pharmacy. [More well worth reading]
As we all get upset one way or another about Obamacare and the website issue, it is important to keep in mind that our status quo has some enormous problems - not the least of which is loss of consumer influence due to third-party payers. For example, my friend is looking at a second round of chemo, and I would almost bet he has no idea what it will cost - or the possible surgery either.

Say what you will about the ACA, but one thing I think is a step in the right direction is the introduction of consumer choices in how much they want to pay in premiums as well as out of pocket costs. Transparency will change consumer behavior, I think quickly. At the same time, many people insured by employers are finally getting some idea how expensive their medical coverage is.
Of course, this is not a discussion I would broach with my very sick friend, but it is clearly one of the biggest reasons we spend so much on medical care in the US compared to other countries.Cancer drugs have become a very big business, even though they serve what one expert has described as a “boutique” market. An estimated 1.7 million Americans will be diagnosed with cancer this year, according to the National Cancer Institute, and more than 580,000 people will die from some form of malignancy. In 2012, the overall market for “oncologics” reached nearly $26 billion a year in the U.S. alone, and annual global sales are projected to total $85 billion by 2016, according to the IMS Institute for Health Informatics.

What is sobering about this booming business is that, as a group of oncologists wrote earlier this year, “most anti-cancer drugs provide minor survival benefits, if at all.” They often (but not always) reduce the size of inoperable tumors, but they rarely eradicate the disease. For relatively uncommon malignancies like testicular cancer, some forms of leukemia, and lymphoma, drugs effectively cure the disease; for the common “solid tumor” cancers (lung, breast, colon, prostate, and so on), which account for the vast majority of annual cases, drugs buy some time—precious time, to be sure, but time usually measured in weeks and months rather than years. And even though many of the newer drugs are less toxic, they often still have to be given with older drugs whose side effects include nausea, hair loss, fatigue, and decreasing blood counts. One anti-cancer drug produces a skin rash so severe and disturbing, according to Saltz, that some patients have been asked by employers not to come to work. [Same]
We are rationing already of course, but informally, and generally by economics, rather than some measure of return on the dollar. The very thought is distasteful, but our squeamishness could direct our economy into one dominated by end-of-life health care. Good news for drug makers and caregivers, but not an optimal or even desired outcome in my view.

Regardless, I know I cannot think rationally about this right now, but wish I could. Grief mixed with protracted suffering makes it hard to think well. And then I get angry for feeling sorry for myself, instead of Dan.

We are exactly the same age as well. Funny how that coincidence rivets your attention as well.

Well, enough sniveling. What I need to do is figure out actions what might ease his struggle, not mine.

1 comment:

Anonymous said...

I really wish that I knew what to pray for in situations like this. I hope your friend and his loved ones can find consolation from a loving God in all this. David