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    Thursday, July 23, 2009

    Cancer Care too Expensive


    “I’ve always maintained, that if you give the Democrats enough rope they’ll hang themselves” said the triumphant new President of the U.S. Sarah Palin. The last straw was denying cancer treatment to her former running mate John McCain when his melanoma returned to the left side of his face. The treatment was denied because of his age by the head Washington D.C. agency established for Equitable Health Distribution (EHD) under the Obama Health reform acts. They did because of his advanced age of being past 70 years old and on the basis of these four developments which in retrospect dynamically converted many pro-lifers into pro-choice.
    The inevitable shift in public opinion tipped the balance to Palin’s pro-life winning election theme. Unfortunately it was too late for the former war hero and presidential candidate McCain.

    1. First “IOM released top 100 comparative effectiveness priorities”
    The stimulus bill "earmarked $400 million for 'comparativeness effectiveness research,'" HHS "asked the Institute of Medicine (IOM), created by Congress to provide advice to policymakers, health professionals, the private sector, and the public, to identify the top priorities on which [healthcare services] to spend the money." In a report , the IOM "listed the top 100 areas of medicine in which research is needed to determine which treatments or preventive measures work best. One of the major areas was cancer treatment. The IOM's research priorities include "remedies for back pain, obesity, and preventing falls in the eldery, as well as studies about how to disseminate the findings to doctors and patients." The 100 recommendations "were selected from some 2,600 suggestions submitted to the committee from professional groups, policy makers and the public

    The NYT praised the IOM's "report as one of the first concrete steps in a broad effort by administration officials and health experts to shift the focus of medical practice toward scientific evidence -- rather than a physician's personal views or treatments promoted by medical product companies.". Insurers, unions, consumer groups, and "many medical researchers" are cited as proponents of comparative effectiveness research, who "say such studies are essential to curbing the widespread use of ineffective treatments."

    2. This was followed by the NEJM.1056/NEJMp0904133) published on June 30, 2009, which stated “This unique opportunity to invest in a major component of the scientific infrastructure for improving health care delivery will be indispensable for achieving a health care system that delivers affordable, high-quality care for all Americans. Physicians and patients deserve the best patient-centered evidence regarding what works, so that Americans can receive care of the highest quality and the best possible outcomes can be achieved.” Also the NEJM explained (10.1056/NEJMp0905631) that the American Recovery and Reinvestment Act of 2009 (ARRA). “which was the $787 billion economic stimulus package that President Barack Obama signed into law on February 17, 2009, included $1.1 billion for Comparative Effectiveness Research [CER]. The research priorities developed by the IOM committee — delivered as Congress requested only 19 weeks after Obama signed the measure — must be taken into account by the DHHS as it allocates $400 million in support of CER projects over the next 2 years. (A Federal Coordinating Council for Comparative Effectiveness Research, a new advisory group created by the ARRA, is also providing input to the DHHS [].)

    3. The third article was a successful trial balloon from the NIH -- Medical Oncology Branch, Center for Cancer Research, National Cancer Institute (TF), and Department of Bioethics, The Clinical Center (CG), National Institutes of Health, Bethesda, MD. Tito Fojo of the National Cancer Institute and Christine Grady at the National Institutes of Health. wrote [ al How Much Is Life Worth: Cetuximab, Non–Small Cell Lung Cancer, and the $440 Billion Question] that “The high price of some of the newest cancer medicines are coming under scrutiny as part of an effort by lawmakers and health officials to rein in overall medical costs.”. Fojo is calling into question the widespread use of expensive cancer drugs to prolong patients' lives by just weeks or months. Fojo states that a study showed that "treating a lung-cancer patient with Erbitux [cetuximab], a drug that costs $80,000 for an 18-week regimen, only prolongs survival by 1.2 months." The authors noted that "based on that estimate, extending the lives of the 550,000 Americans who die of cancer annually by one year would cost $440 billion." The authors argued that "health professionals and researchers cannot ignore costs in setting treatment standards.These authors also "questioned the cost-benefit calculus for other big cancer drugs " calling "for changes in the testing and practice of medicine—despite the fact drugmakers say this article exaggerated the overall costs of their treatments because few patients are on them for extended periods of time."

    4. Going even further the NIH authors stated that “Studies of cancer drugs that are expected to find survival advantages of two months or less should be undertaken only if the treatment costs less than $20,000.” Otherwise, they say the research community will waste valuable resources pursuing therapies that the healthcare system can't afford to provide. "We naturally avoid confronting the tension between not wanting to put a value on a life and having limited resources. But the spiraling cost of cancer care in particular makes this dilemma inescapable."They continued, "We must stop deluding ourselves into thinking that prescribing expensive chemotherapies and tests is an aberration, a temporary deviation from an otherwise reasonable cost trajectory."More than 90% of all new anticancer drugs receiving FDA approval in the past four years cost more than $20,000 for a 12-week course of treatment, they said.Drs. Fojo and Grady even rejected the argument that cost-benefit ratios will improve through identification of patient subgroups who are more or less likely than average to respond to a given drug.

    5. Drs. Fojo and Grady recommended a series of policies that were immediately implemented with the new health reform acts.:

    • Anticipated treatment costs should be coupled to trial designs, such that the endpoint benefit should cost no more for a quality-adjusted life-year than renal dialysis -- currently $129,000.

    • Drugs that work for a particular patient subset "should be advocated, approved, and prescribed for that subset only."

    • Clinicians should not prescribe beyond FDA-approved indications -- such as giving treatment-resistant or refractory patients a drug approved only as first-line therapy.

    • "The all too common practice of administering a new, marginally beneficial drug to a patient with advanced cancer should be strongly discouraged. In cases where there are no further treatment options, emphasis should be first on quality of life and then cost."

    • Toxicities should receive extra scrutiny for drugs with marginal benefits.
    Fojo T, et al "How much is life worth: cetuximab, non-small cell lung cancer, and the $440 billion question" J NATL CANCER INST 2009; DOI: 10.1093/jnci/djp177.

    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    * Tune in tomorrow for How to Find a Good Hospital.

    Deepen your understanding of "medical malpractice"...

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