Prostate Drug Costs

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Most readers will have seen something in the popular press over the last 6 months regarding the increasing awareness of oncology drug costs. For example, there have been very nice commentaries in the New England Journal of Medicine like this one, that deals with the cost of nivolumab, a PD-1 pathway inhibitor that is approved for treating melanoma and may show promise in a number of other cancers like kidney cancer. The final paragraph is telling:

Hand clapping for science is now inextricably linked to hand wringing over affordability. Drug prices are increasing more rapidly than their benefits, and the growth in spending on drugs has started to outstrip growth in other areas of health care. Addressing this problem requires realizing that cost-effectiveness assessment — a step that we are not even ready for in the United States — has limitations when one considers the price of the comparator and the impact on overall budgets.

I have opined elsewhere in this blog site on the excitement over the new immune-stimulating drugs that show promise. Indeed, some may be able to improve the response to prostate vaccine approaches. The question is whether we can afford all of these drugs, who decides, how they decide, and what methods they use. In the past, a QALY (quality adjusted life year) has been used to benchmark some of the things we do in medicine. In a nice NEJM perspective article, the classic “$50,000/QALY” benchmark was reviewed, but the authors suggested that given medical progress and inflation, a more realistic number might be as high as $100,000 or $150,000. The costs of the newer prostate cancer drugs such as abiraterone, enzalutamide, sipuleucel-T, cabazitaxel etc. have not escaped attention. Medscape had an article on this over 2 years ago. I am no expert on Markov models, differing ways to evaluate cost-effectiveness, and the economics of medicine. But as a simple way of explaining the challenge, how much is cisplatin, a cornerstone of curative treatment for testis cancer, the number one cancer of young men in their 20’s worth? If you can answer that, then how much would it be worth if you were using the same drug as a third line to treat prostate cancer, where responses are rare except in the case of the small cell variant, but no one is cured? In the case of the young testis cancer patient, many years (or QALY’s) are achieved while in the case of even the “sensitive” form of prostate cancer, the benefit would be in months at best. Should testis cancer patients have to pay huge sums because it works so well for them and prostate cancer patients less? And how do we figure in the drug development costs in a fair way that retains a financial incentive for the pharmaceutical companies and researchers to keep working for new discoveries?

Added to this is my own experience when I have described using a highly expensive (sometimes toxic) drug to a patient with well-known, very limited (but measurable, approved, and “covered” by Medicare or insurance) benefit. Often when I am honest and say, “this may help for a while, but is not a cure,” to a patient who may have very few symptoms at all but is progressing based on a rising PSA, the reply will be “what choice do I have”? That is a great question. If someone else is paying for some very expensive drug, why not try it? Although I know that the ethicists feel “my wishful answer” is unethical, I would like to be able to say something like this: “Well Mr. Smitherton, Medicare has decided that if you would rather take the money and apply it to your grandchild’s college fund, they will be willing to divert the costs (or some proportion of them) to that cause because ‘we’ [society] feel that should be your choice, rather than having us pay for a relatively ineffective, expensive drug if you don’t think it is worth it, or if you value his/her education over a few months of additional life span.” If wishes were horses, beggars would ride. And if I was qualified in ethics, I would probably not be writing this. That’s my 2¢ – or maybe it should be my $20,000??

6 Comments

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6 responses to “Prostate Drug Costs

  1. Joe Blue

    What a GREAT idea. And it would have more support among economists than you give yourself credit for.

  2. Dan

    Great Article Dr. Glode,
    As a guy who was refractory to primary adt 8 years ago, and still pre chemo with addition of the expensive drugs zytiga and xtandi, plus some estrogen, and keto, I certainly am grateful for good insurance. Going forward I am hopeful for a good response to chemo.
    PD1 inhibitors are all the buzz lately, what can you tell us about this class of drugs, as I understand it the response in Prostate Cancer has not been so good.
    thank You
    Dan

  3. john

    BEING MORTAL has prepared me for NOT requesting any of those drugs of short term life extension. Thank you for your thought piece John

    • Dan

      John, I would like to say that the medium survival indicated is not the message, Sometimes Men get a lot more time ot of these drugs as in my case ,my life was forecasted to end almost nine years ago, and as of yesterday I am currently stable on the expensive drugs, happy for insurance that covers them, and thankful for the researchers and those in clinical trials that got them approved, xtandi was supposed to stop working 3 years ago for me, and it is still working.
      Dan

      • Dan, I just read this and I’m so happy that you are doing so well.  I agree with you because I’m pretty sure Craig made it ten years because of all the new drugs.  The fact that you have an opportunity to try something new gives you hope and I believe our bodies thrive when there is hope.  Keep up the good work! Suzanne

         Craig BeckerThe New Denver Men’s Club  Blog: http://newdenvermensclub.wordpress.com/ “Men Fighting Cancer To Win”

      • Dan

        Suzanne,
        Thank You, Yes this is me. I certainly do feel fortunate to have these drugs when I need them so bad and thankful that the side effects do not really bother Me to much, and to know that the researchers are coming up with new therapies all the time. I think of Craig often, and went on the DMC site yesterday. He really helped a lot of us.
        live every day!
        Dan

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