TREATMENT for colorectal cancer has come a long way since the mid-1990s. The best option then was a chemotherapy agent called , which let patients with metastatic tumours survive for about a year, rather than eight months if they just received palliative care. A clutch of new drugs has since doubled survival times. There is a downside, though. According to an analysis conducted in 2004 these drugs increased treatment costs 340-fold (The New England Journal of Medicine, vol 351, p 317).
It鈥檚 a similar story right across oncology. With many cancer drugs costing tens of thousands of dollars a year, they have become a flashpoint for anguished debate. This will only intensify, given the predicted future of cancer therapy (see 鈥淎t peace with cancer鈥�). The genomic revolution brings the possibility of devising cocktails of drugs targeted to the particular mutations that are driving each patient鈥檚 tumours, allowing people to live for many more years. If we are struggling to pay even for today鈥檚 cancer drugs, how will we afford this vision?
鈥淚f we are struggling to pay for today鈥檚 cancer drugs, how will we afford those targeted to each patient鈥檚 tumours?鈥�
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First we need to ask why cancer drugs are so expensive. Pharmaceutical companies point to the huge costs of drug development: estimates for a biological product such as an anti-cancer antibody run as high as $1.3 billion. More than half of this is spent on the clinical trials needed to satisfy regulators that a drug is safe and effective.
The cost of such trials could be brought down by recruiting only patients whose cancers have genetic profiles that make them susceptible to a certain experimental drug. This is not happening enough: drugs are often tested on people who could not possibly benefit from them, making the trials inefficient. What we need is more volunteers, so more people with the desired genetic profiles can be identified. At present only 3 per cent of adult cancer patients are enrolled in clinical trials, so there is plenty of room for improvement. In the past, as many as 80 per cent of youngsters with some childhood cancers have been treated in clinical trials.
These savings may be wiped out, however, if genetic targeting breaks down once drugs get into doctors鈥� hands. This has been a problem with , or Herceptin, an antibody that targets breast cancer cells with an over-abundance of a receptor called HER2. Women whose tumours lack the mutation responsible cannot benefit. But when the insurance firm United 午夜福利1000集合care examined US patient records two years ago, it found that 12 per cent of women receiving the drug either had not been tested or had a negative result for the mutation.
For some drugs, we do not yet have the tests to predict who will benefit. Here, it may be necessary to change how pharmaceutical companies are paid. Last year, the UK National 午夜福利1000集合 Service (NHS) struck a novel deal with Janssen-Cilag, which markets a multiple myeloma drug called , or Velcade. Under the deal, payment is made only for those patients who respond well, generally around two-thirds.
This agreement came about because the NHS has an adviser on the cost-effectiveness of new drugs 鈥� the UK government鈥檚 . If NICE finds that a drug costs more than 拢30,000 to deliver a , a statistic that measures both survival and quality of life, it has little chance of being used within the NHS. Bortezomib failed this test, prompting Janssen-Cilag to propose the unusual payment scheme.
The cost of clinical research may be high, but the main reason that cancer drugs are so expensive is that historically, around the world, manufacturers have often been able to name their price 鈥� exploiting the fact that no one wants to say 鈥渘o鈥� to the terminally ill. This needs to change, especially in the US, which has the largest market for cancer drugs and consequently the muscle to shake things up.
If there is one positive result from the present implosion of the global economy, it may be to embolden political leaders to stop writing blank cheques to drug firms, and pave the way for a future in which new, cheaper drugs enable us to live with cancer as a chronic disease. If governments and insurers fail to take a tougher negotiating stance, rising prices will deny future clinical advances to increasing numbers of people with cancer.
