COMMENTARY

Expert Insight: How Much is Too Much When it Comes to the Cost of Cancer Care?

Karol Sikora, PhD, FRCR, FRCP, FFPM

Disclosures

July 09, 2018

I'm Professor Karol Sikora. I'm going to talk about the economics of cancer care.

I've spent nearly 40 years as a consultant in Britain and what I've seen is a remarkable growth/increase in the cost of delivering optimal cancer care. It's the same in all countries. Different countries are dealing with the matter in different ways. In the last decade, there's been a particular escalation. Ten years ago I co-edited a book on the economics of cancer care.[1] Now you have to add several noughts the figures quoted in there and that's not going to stop. It's going to get worse and worse.

Paying the Price

So the fundamental question is how much would you pay if you have cancer? It doesn't matter whether you're paying through taxes, through insurance, or self-pay, someone has to pay the price. Say it was a pound to get a cure for cancer, everyone would buy it, there's no doubt. Say it was a million pounds. It's not possible. It's not feasible to double the cost of NHS care, simply because you're paying a million pounds to cure cancer. And that's the conundrum. Nobody has the answer.

There's only three ways to pay for care, tax, insurance, and self-pay, and a mixture, and most countries have a mixture. We're slightly different in England with the NHS predominantly providing cancer care. And so we have to look to government's taxation to try and sort the problem out.

So where are things coming from? Why is it going higher and higher? The problem is that we don't get rid of the old. In any system in which you retain what we were doing before and then add to it, you inevitably increase the costs. And we've seen a real escalation in the costs of drugs.

Rising Costs

So when I used to manage the budget at Hammersmith and Charing Cross Hospitals [In London], the most expensive problem I had was Taxol (paclitaxel) and carboplatin (Paraplatin), both of which are now generic. And the costs were about £5000 pounds, of course, this is back in the 90s. Clearly now there are drugs costing nearly half a million pounds to give and that's without the management of sometimes profound side-effects which require intensive therapy, which is very expensive in itself. So the future of oncology is not just about innovation, and how to deliver it, the systems around us, delivery at home, in clinics and day centres and so on, but how we really pay for care in the future.

And the other problem, which is not addressed by health technology agencies, NICE [The National Institute for Health and Care Excellence] is perhaps the first, and arguably probably the best of all the European agencies, is how do we factor age into it and the quality of life?

Age and Decision Making

So if you asked this basic question, if a man of 40, with a young family has cancer, would you spend more on him than a 90 year old with dementia in a care home? And these are the sorts of problems we're going to get into in the future. I would argue that you should be ageist about it. I'm just 70 so I'm an old person myself, and I would argue we should be ageist about it, there's nothing wrong with that. The NHS and NICE are religiously against doing that. But realistically, the length of my life compared to, even if I didn't have cancer, compared to a 40 year old is clearly not the same, and therefore, one should tailor it to my expectations of future survival. The second problem, is with it you allow people to treat themselves, to add to the budget for their own care. And that is what is very difficult within the NHS, called co-payments or top up payments. No one likes it, and people have political persuasions about whether we should allow it. But it is one way of allowing people to receive expensive treatments without breaking the bank of the whole system.

Every country has the problem. Poorer countries can't even get what we would accept as routine care. Adjuvant chemotherapy for breast cancer, for example, they just can't afford the drugs. We're in a difficult position we're actually well off. We're well-funded in healthcare. We would argue there's not enough in the NHS, but when you compare it with Uganda or Sub-Saharan African countries we’re really relatively well off.

Reducing Costs

So how can we reduce the costs? Well, the most obvious way is not to give ineffective therapies and that is a huge problem. How do you identify ineffective therapies?

We're in an era of genomic medicine, analysing DNA, looking at sequences that predict responses. And in theory, that's how we're going to get over the problem. We will only give the right drug to the right patient. Personalised medicine will solve it. But there's a super paper that I really commend you in the Journal of American Medical Association Oncology in April of this year,[2] that looks at the number of cancer patients in the United States that benefit from genomic medicine. In other words, cancer drugs that require a prerequisite test prior to their administration, a predictive test of response. So we're all familiar with Herceptin, one of the first drugs, Tamoxifen even before for oestrogen receptor. And now the wonderful story of crizotinib (Xalkori, Pfizer) in a ALK positive lung cancer.

So unfortunately, although there are 31 targeted compounds like that with a genomic test, the study published in April shows that less than 7% of patients with metastatic cancer actually gain from any clinical benefit from this approach.

Genomic Medicine

Now, that will get better as time goes by. But it's going to take years. And it probably won't come until we have the projects like The 100,000 Genomes Project, of our own Department of Health to try and use big data to analyse which patient to give which drug, and then the costs, in theory, will come down. The pharma industry, it delivers drugs and in some cases diagnostics to go with those drugs. But it's not able to reduce the costs significantly. So we have to look internally how we can select patients for the right treatment and to factor in the innate quality of life consequences of giving a drug. A drug that gives you poor quality of life because of side-effects and very little survival benefit probably should be written out.

And predicting what's going to happen in an individual patient is going to be very much part of our future. So the future oncologists will be just like GPs today, focused on their computers, hopefully being kind and empathic with their patients, to try and work out the best for an individual.

Individualised care is really again, to come, the same with radiotherapy, the same with surgery, and certainly with systemic agents.

Thanks for watching. Carol Sikora here. Any comments please get in touch.

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