Solutions Needed to Stem Cancer Costs, ASH Experts Say

Roxanne Nelson

December 16, 2014

San Francisco, CA — The United States spends more on healthcare than any other nation in the world, and many agree that the current growth rate of healthcare expenditures is unsustainable. One contributing factor to rising healthcare costs is the cost of new drugs, and oncology drugs in particular. In a special session held here at the 56th Annual Meeting of the American Society of Hematology (ASH), an expert panel came together for a frank discussion about this aspect of cancer care, and hopefully to identify solutions to curb the spiraling costs.

Hagop M. Kantarjian, MD, professor, department of leukemia, University of Texas MD Anderson Cancer Center, Houston, kicked off the discussion with a provocative talk about drug pricing. Not mincing words, he squarely put the blame for high drug prices on the pharmaceutical industry.

This is a theme he has been highlighting for some time now, starting with an explosive paper in the journal Blood last year and most recently appearing on the prime time US television 60 Minutes, where he described the high prices that industry is charging for new cancer drugs as "unreasonable, unsustainable, and, in my opinion, immoral."

Dr Kantarjian noted that cancer drug prices have jumped 10-fold during the past decade, and pointed out that before 2000 the average price for a cancer drug was $5000.

In contrast, three drugs for chronic myelogenous leukemia (CML) came on the market in 2012 with a price tag of $100,000 a year. In addition, the price of imatinib (Glivec, Novartis) jumped from $28,000 to $92,000 during the past decade. And these prices, Dr Kantarjian emphasized, are not just for CML. "They are across the board."

"Are these costs too high? Are they harming our patients?" he asked.

The answer is a resolute yes. "And I believe that as a physician, we have to protect our patients at the individual and society level," Dr Kantarjian said. "When drugs are not affordable, then they are harming the patient."

High costs also do not necessarily equate to better outcomes. Despite treatment for CML being 30% lower in Sweden compared with that in the US, the outcomes are better — overall survival is 80% at eight to 10 years in Sweden compared with 60% in the US, he noted.

Dr Kantarjian also pointed out that high out-of-pocket costs are leading patients to personal bankruptcy, adherence issues, and mental stress.

There are a number of solutions that could help stem the rising costs, he explained. One is for increased and continuing participation in the discussions by major medical societies, such as ASH and the American Society of Clinical Oncology. Another is to allow Medicare to negotiate drug prices, which is currently forbidden by federal law, and to allow importation of drugs.

The practice of "pay for delay," which allows generic drug competition to be blocked for growing numbers of branded drugs, also needs to be stopped, he added.

Unintended Consequences

The discussion switched gears with Alex W. Bastian, MBA, who presented a different viewpoint of the situation. As vice president, Market Access, GfK Bridgehead, which provides consulting services to healthcare global companies in pharmaceutical, biotechnology, medical device, and diagnostics industries, he attempted to explain some of the issues surrounding healthcare — and drug costs — in particular.

Bastian emphasized that this is not an issue that the US is facing alone but "that it is a global problem."

That said, he also pointed out that despite the growth in healthcare spending the cost for cancer care has remained small, about 5% of the total expenditure.

However, while the skyrocketing cost of drugs cannot be ignored, attention needs to be focused on the value of therapy rather than cost. Cost itself should not be the focus but rather value, he said.

"We need to focus on what matters most," Bastian said. "If we talk about cost, then the cost to who?"

The average cancer patient spends about $5000 during their first year following diagnosis, and about $1000 to $25,000 for the entire course of treatment, he explained.

Continuing with the concept of value, Bastian noted that other influences are important. The first drugs were approved for Hodgkin's lymphoma and leukemia 65 years ago. "This demonstrates the long standing commitment we have had with research," he said, and added that there has a doubling and trebling of longevity.

However, the number of therapeutics in hematology are still dramatically lower than for solid tumors, Bastian continued. "There are some reasons for this but it also highlights the difficulties in developing therapeutics for hematologic malignancies."

For example, even though the number of FDA-approved drugs rose during the period of 1998-2014, a total of 249 drugs in development for hematologic cancers failed to make it out of the pipeline.

This brings it to the idea of "unintended consequences," he said. "It's not that current therapeutics are being sold at a high price to pay for past investments but quite the contrary. High prices and healthy margins justify the continued investments for future therapies."

The healthcare system is complicated in the US, and part of "American style capitalism," Bastian noted, but he reiterated the importance of value, adding that "it is important to look at the total cost and the benefits."

While he admits that he doesn't have all the answers, Bastian emphasized that a long-term view of the situation is needed, and one that takes into consideration the total benefits that a drug might yield, which can prevent downstream cost of care.

Discussions Can Lower Costs

S. Yousuf Zafar, MD, MHS, associate professor of medicine at Duke University, Durham, North Carolina, described how patients are now grappling with costs, and also presented a study about cost discussion between providers and patients.

"The average cancer patient spends about $5000 out of pocket," said Dr Zafar. "The cost of insurance premiums have also gone up. They have increased by 182% and worker contributions to employee plans have gone up 128%, from 2006."

Tiered formularies for drugs have become increasingly more common. In 2003 there were no fourth-tier drugs, and now 23% of drugs in 2013 are fourth tier, he pointed, and this usually includes all oral chemotherapy agents.

With mounting costs and increasing out-of-pocket expenses, there is a need to integrate costs into clinical decision-making, he said. He also noted that a report issued by the Institute of Medicine recommended that patients be provided with understandable information on costs of care.

To gain more information about patients' preferences for incorporating cost discussions into cancer treatment decision-making, Dr Zafar and his group conducted a prospective, longitudinal study to see if patients wanted to discuss treatment costs with their clinician. They also looked at the willingness of patients to incorporate costs into treatment decision-making, and if they found cost discussions useful in lowering out-of-pocket expenses.

Dr Zafar explained that of the 300 patients that were surveyed, 52% expressed some desire to discuss treatment-related out-of-pocket costs with their doctor, and 51% wanted their doctor to take costs into account to some degree when making treatment decisions. However, only 19% had actually discussed cost with their physician. But for those who discussed cost, more than half (57%) reported lower out-of-pocket costs as a result of these discussions.

"Our study highlights that patient-physician cost communication can reduce out-of-pocket costs even in oncology where treatment options are often limited," he said. "It is important to recognize patients at risk for financial toxicity."

Following the panel talks was a Q & A session that resulted in a lively and animated discussion between the panel and audience. Several attendees spoke on their experiences as cancer patients and physicians, and how these very expensive but effective drugs had helped them. One physician who had also been a cancer patient reiterated the importance of involving the patient in any cost-effectiveness discussion, whether it be with their own oncologist or at a policy level.

American Society of Hematology (ASH) 56th Annual Meeting: Presented December 6, 2014.

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