John L. Marshall, MD; Bruce D. Cheson, MD; David Kerr, CBE, MD, DSc, FRCP, FMedSci


June 10, 2013

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In This Article


John L. Marshall, MD: Hello. I am John Marshall, Professor of Medicine at Georgetown University and Director of Clinical Research for the Lombardi Comprehensive Cancer Center in Washington, DC. Welcome to this edition of Medscape Oncology Insights from the American Society of Clinical Oncology (ASCO®) annual meeting.

Today we have a roundtable discussion on one of the most difficult topics there is: managing the financial toxicities of cancer drugs. I am joined today by 2 outstanding experts and very insightful folks in the world of cancer, cancer drugs, and value. First, let me introduce my good friend and partner, Dr. Bruce Cheson. He is the Deputy Chief of Hematology/Oncology and Head of Hematology at Georgetown University Hospital right down the hall from me at Lombardi Comprehensive Cancer Center in Washington DC. Bruce, welcome.

Bruce D. Cheson, MD: Thank you.

Dr. Marshall: Let me also introduce a good friend and colleague, Dr. David Kerr, who flew all the way over the big pond to be with us here in Chicago. He is Professor of Cancer Medicine from the University of Oxford and former President of the European Society for Medical Oncology, but he still feels like the President to me. David, welcome.

David Kerr, CBE, MD, DSc, FRCP, FMedSci: It's great to see you again, John.

Oncologists Decry Costs of Cancer Care

Dr. Marshall: We have been assigned a very difficult topic to discuss. We have been grumbling about this in the back hallways for a long time. The costs of cancer care have now become a mainstream topic for us in presentations in big rooms at ASCO, and we are trying to drill down on this. More and more oncologists have taken on a more activist role and are trying to balance out the discussion, making sure that folks get a good sense of what is going on out there.

Recently, there was a hot little paper, signed by 120 leukemia researchers, by Hagop Kantjarian. He published what amounts to a position paper in Blood [1]decrying the high cost of cancer drugs. Bruce, what was your reaction to this, and what is the spirit of this protest?

Dr. Cheson: I was proud of him. I have known Hagop for a long time and he is a leader in this field [of leukemia research]. The situation he describes is disturbing. Imatinib made the cover of TIME magazine as the cure for cancer, the magic bullet.[2] When it first came out about a decade ago, it cost $32,000 a year, which was a lot of money. Now it is more than $95,000 a year, and all the other [tyrosine kinase inhibitors] -- dasatinib and erlotinib -- are now $130,000 a year. It's to the point that, in other countries, it is cheaper to do an allogeneic bone marrow transplant than to give someone a kinase inhibitor.

It's disturbing because there are people who have out-of-pocket costs that are so high that they become noncompliant.[3]These are drugs that you have to take every day or the leukemia comes back, and then you're in trouble.

So, it is very disturbing and I am glad that he brought this out into the open for discussion and debate. It has stimulated a lot of discussion.

Dr. Marshall: But come on. When I first started taking care of chronic myeloid leukemia (CML), the chemotherapy was terrible. It didn't work. People were dying. With this drug, you get a little eye puffiness and your leukemia goes away. Isn't it worth it?

Dr. Cheson: It is, if you can afford it. But what it does to the economy -- this is just one of a series of drugs in lymphoma. We have a plethora -- do you like that word, "plethora"?

Dr. Kerr: My vocabulary has been expanding at unprecedented speed.

Dr. Cheson: We have a plethora of new kinase inhibitors that are revolutionizing how we think about lymphoma and chronic lymphocytic leukemia (CLL), and that is all you hear about. But once these drugs make it to the market, it's not going to be chlorambucil anymore at a nickel a pill. It's going to be ibrutinib or idelalisib or one of those other drugs at $100,000 or more a year. We are going to have to see the value in those drugs. We are going to have to weigh the costs. We say "cost-benefit" now in a different framework than what we used to do. The world is changing. But can the economy support it?

Dr. Marshall: When you get nilotinib after imatinib and it works a little better, not a lot better, but a little better, and you are charged a lot more -- is that part of the problem, that you have to "one-up" the last drug and make your money off of it?

Dr. Cheson: You have 5 of these drugs out there. You would think that competition would bring the price down. It didn't happen one bit. It's crazy.


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