[Ip-health] UK Med School Dean: Cancer medicine: a scientific dream turns into an economic nightmare
james.love at keionline.org
Sun Jun 29 02:23:40 PDT 2014
Cancer medicine: a scientific dream turns into an economic nightmare
Professor Karol Sikora*
02nd June 2014
*Professor Karol Sikora, Chief Medical Officer of Cancer Partners UK and
Dean at the University of Buckingham Medical School explores the current
landscape of cancer treatments.
Drug companies have few friends left. Perceived like the banks as evil
symbols of corporate greed, they are increasingly portrayed as the bad guys
in the saga of high cost novel cancer drugs. This seems a little unfair as
without the huge and often risky investment required no drug would ever get
The recent incredible discoveries in genetics, signal transduction, cell
interaction and immunology have heralded a mechanistic approach to cancer
drug discovery. The large scale screening approach which gave us a
remarkable generation of cytotoxics such as taxol, doxorubicin, platinum
and vincristine has given way to a far more intellectually satisfying
approach of a new generation of targeted molecular therapeutics. But their
costs to the patient and insurers have escalated beyond belief 1. Sure,
research is expensive and it's true that drugs make up less than 10% of the
cancer budget. But we have seen the monthly cost of a box of cancer pills
escalate from a few pounds to over £8,000 over a decade.
"...we have seen the monthly cost of a box of cancer pills escalate from a
few pounds to over £8,000 over a decade."
As Western governments and insurers struggle to control runaway healthcare
budgets caused both by escalating costs of technology and their aging but
demanding populations, the hunt is on for scapegoats. In a sound-bite
dominated world who better to go for but the junketing high flyers of
pharma with their private jets and Armani suits to deflect the public's
anger. Yet clever marketing strategies with crisp three symbol trade names
bought for millions of dollars from leading New York advertising agencies
create an image of success and stimulate demand.
Personalised medicine is here to stay for cancer. The problem is that at
the moment its fragmented. Truly useful molecular response predictors are
only available for a few of our expensive therapeutics such as herceptin,
crizotinib, imatinib, vemurafinib and rituximab. For others some hints can
be obtained from markers such as Kras mutation or hormonal receptor
expression but these are not absolute 2. But for most, including some of
the biggest blockbusters there are simply no predictive biomarkers
available for patient selection.
As we get better at making predictions we should be able to reduce costs by
only giving the right drug to the right patient but we're not there yet.
Perhaps the biggest problem affecting payers is the poor efficacy of many
of the new compounds, however clever their mechanistic basis. Why should
society be expected to pay £70,000 for an elderly man with prostate cancer
to survive for another three months? Or a similar price for a young woman
with breast cancer to take sixth line chemotherapy for only a few weeks
extra of life.
The high prices of new cancer drugs represent a moral blackmail on society.
If we don't pay for them through tax or insurance we are seen as a hard,
heartless society with no compassion forcing cancer victims to sell their
homes and cars to raise the necessary cash. But there's plenty more in the
pipeline so the problems will only escalate (Table 1). It's true, some of
the blockbusters will soon be generic: rituximab (2014); imatinib (2015);
bevacizumab (2018) and erlotinib (2020) but the savings will soon be
gobbled up by the price of the new.
Table 1: Current cancer drug pipeline April 2014
The politics are complex. No elected official wants to be seen denying
cancer patients life-saving medication. And industry has been great at
hyping the value of many of its products egged on by publicity hungry
cancer charities keen to get donations. Somehow the meagre survival benefit
never seems to appear in the adverts or press releases of either.
"Why should society be expected to pay £70,000 for an elderly man with
prostate cancer to survive for another three months?"
In the UK several confusing processes have emerged all aimed at distancing
politicians from individual patients. These include the use of neutral
health technology assessments through NICE; the creation of a National
Cancer Drugs Fund 3 with its own approved list separate to that of NICE; a
complicated innovative medicines access scheme and a plethora of supposedly
value-based schemes that include free treatment to ascertain if a patient
responds, a yearly maximum price for a single patient, cash back after
purchase, single lifetime purchase and price equalisation to existing
therapies. If only we used the same imagination in drug discovery as in
developing novel marketing strategies we probably would have far higher
tumour response rates.
These new drugs will probably never cure cancer for most people. They will
just add a small benefit to some patients but we can't always predict who.
In metastatic cancer we are operating too far along the therapeutic
plateau. Generally the more we spend on healthcare the better the outcome.
But for every disease we reach a horizontal limit – spending more money
gives little real gain. But to know there is something out there we can't
have that just might make a difference is psychologically very damaging for
cancer patients and their families 4. And the cancer market and its prices
are dominated by one country – the USA – home to 4.8 percent of the world's
population yet consuming over 70 percent of its cancer drugs in dollar
To make matters worse we don't have good data on the true value of new
compounds versus cheaper available treatments simply because it's too
expensive to do the relevant trials to show non-inferiority. It's just not
in the interest of the manufacturer to do such comparisons or to provide
the new drug freely for such studies. The economics are a true nightmare.
If we assume that each patient with metastatic cancer – about 100,000 a
year in the UK – needs novel drugs with an average cost including IV
administration and side effect management of £100,000 then the total
addition to the NHS budget is £10bn. Such a dramatic hike is simply not
So cancer drug rationing is inevitable in all health economies – rich and
poor alike. My solution is to have age limits for expensive therapies.
Oncologists have been doing this covertly for the last two decades – it's
now time to be explicit. This seems only fair when the value of giving
£100,000 of cancer drug is going to have a much greater potential benefit
in someone whose life expectancy is 40 years rather than five. But is that
knock on the door the NHS thought police summoning me for corrective
Table 2: Top 25 new releases 2012–14 – at least £20,000 needs to be added
to cover administration costs often by IV pump and the management of side
1. Sullivan R, Peppercorn, Sikora K et al
Lancet Commission: Delivering affordable cancer care in high income
Lancet Oncol 2011: 12; 933-80
2. Siddiqui M and Jajkumar S
The high cost of cancer drugs and what we can do about it
Mayo Clin Proc 2012: 87; 935-43
3. National Cancer Drugs Fund List February 2014
4. Mailankody S and Prasad V
Comparative effectiveness in oncology
New Engl. J Med 2014:370; 1478-81
About the author:
Karol Sikora is Medical Director of Cancer Partners UK a group creating the
largest independent UK cancer network. He is also Dean at the University of
Buckingham Medical School.
James Love. Knowledge Ecology International
http://www.keionline.org, KEI DC tel: +1.202.332.2670, US Mobile:
+1.202.361.3040, Geneva Mobile: +41.76.413.6584, twitter.com/jamie_love
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