In Cancer Care, Value Matters More Than Cost

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  • 10/17/2012
An editorial  in the NYT -- " In Cancer Care, Cost Matters" --explains why Memorial Sloan Kettering has decided not to use a new angiogenesis drug from Sanofi called Zaltrap.   I am sure the article will trigger an either or debate about rationing, especially among those who hate medical progress because it's a product of capitalism (Marcia Angell, Merrill Goozner, Maggie Mahar) but the editorial is more thoughtful and science-based than those who will wave it around to make the case for rationing.  

Read the entire article but here's the gist of the piece:

"AT Memorial Sloan-Kettering Cancer Center, we recently made a decision that should have been a no-brainer: we are not going to give a phenomenally expensive new cancer drug to our patients.

The reasons are simple: The drug, Zaltrap, has proved to be no better than a similar medicine we already have for advanced colorectal cancer, while its price — at $11,063 on average for a month of treatment — is more than twice as high.Ignoring the cost of care, though, is no longer tenable. Soaring spending has presented the medical community with a new obligation. When choosing treatments for a patient, we have to consider the financial strains they may cause alongside the benefits they might deliver....

This is particularly the case with cancer, where the cost of drugs, and of care over all, has risen precipitously. The typical new cancer drug coming on the market a decade ago cost about $4,500 per month (in 2012 dollars); since 2010 the median price has been around $10,000. Two of the new cancer drugs cost more than $35,000 each per month of treatment.

The burden of this cost is borne, increasingly, by patients themselves — and the effects can be devastating. In 2006, one-quarter of cancer patients reported that they had used up all or most of their savings paying for care; a study last year reported that 2 percent of cancer patients were driven into bankruptcy by their illness and its treatment. One in 10 cancer patients now reports spending more than $18,000 out of pocket on care."

...Avastin costs roughly $5,000 a month: very expensive in its own right, yet less than half of Zaltrap’s price tag. And while the side effects in both drugs are roughly equal, doses of Avastin generally take less time to administer than those of Zaltrap, which makes Avastin more convenient for patients."

When all is said an done, cancer drugs are less than 7 percent of all prescription drug spending.   The objections regarding price -- all things being equal -- overlook the cumulative contribution of medical innovation to longer survival, greater health value and lower treatment costs compared to caring for someone who is terminally ill.  

But the NYT editorial doesn't say all new drugs are useless or shouldn't be used until and unless proven cost-effective, the default position of the professional class making a bundle off of comparative effectiveness grants.  

Rather, it takes into account something the comparative effectiveness crowd never considers:   convenience to patients -- a key element to the value proposition in terms of adherence and outcomes. 

Avastin actually takes less infusion time – the standard being 90 1st dose, 60 2nd dose, then 30 thereafter.  Zaltrap is 60 minutes each time.  Avg number of doses in the trial is 7 and change, so infusion time for Avastin is about 2hours less for average patient.  That doesn't seem like a big deal but over the course of months, the waiting and preparation not only imposes a cost on patients but could also discourage compliance.  

So what if people don't respond to Avastin.  Will the Sanofi drug be used.   And is it really a matter of selecting one over another.  A recent study asked this  post-avastin question.  Sticking with Avastin  (but changing the chemo) prolongs life as much as changing the chemo and going from Avastin to zaltrap.  Response rates in the study were small but showed that within a subset of patients being treated for cancers guided by a VEGF-mechanism for longer periods of time increaes survival.   

Clinical trials that seek to compare an existing product with a new one are costly and difficult to run because who wants to enroll in them?  But the Sanofi drug could be used if it is found to work in a group of patients based upon KRAS mutation or variations in the VEGF signaling pathway..    Information like this can be obtained during clinical trials or in real world settings.  The cost and time of producing such findings are dropping as is the process of matching such results to meaningful patient-level outcomes including "hassle" and quality of life.  

Perhaps a better title for the op-ed should be In Cancer Care,  Value Matters More Than Cost.   Does a product prevent a disease from spreading?  Does it reduce the time and cost that someone with cancer have to bear?  Does it reduce the complexity of treating an illness?  And finally, what is the most effective, most convenient and less toxic treatment for individual patients?

Those are the questions MSK sought to ask and answer in a compassionate way.


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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