$93,000 cancer drug: How much is a life worth?
Photo 
In this Aug. 16, 2010 photo, patient Bob Svensson is hooked up to a blood infusion machine under the care of Nancy Grant, a registered nurse at the American Red Cross in Dedham, Mass., as he undergoes a $93,000 prostate cancer treatment. The Provenge therapy, approved in April, adds four months' survival, on average, for men with incurable prostate tumors. Bob Svensson is honest about why he got it: insurance paid. "I would not spend that money," because the benefit doesn't seem worth it, says Svensson, 80, a former corporate finance officer from Bedford, Mass.
BOSTON — Cancer patients, brace yourselves. Many new drug treatments cost nearly $100,000 a year, sparking fresh debate about how much a few months more of life is worth.
The latest is Provenge, a first-of-a-kind therapy approved in April. It costs $93,000 and adds four months' survival, on average, for men with incurable prostate tumors. Bob Svensson is honest about why he got it: insurance paid.
"I would not spend that money," because the benefit doesn't seem worth it, says Svensson, 80, a former corporate finance officer from Bedford, Mass.
His supplemental Medicare plan is paying while the government decides whether basic Medicare will cover Provenge and for whom. The tab for taxpayers could be huge — prostate is the most common cancer in American men. Most of those who have it will be eligible for Medicare, and Provenge will be an option for many late-stage cases. A meeting to consider Medicare coverage is set for Nov. 17.
"I don't know how they're going to deal with that kind of issue," said Svensson, who was treated at the Lahey Clinic Medical Center in suburban Boston. "I feel very lucky."
For the last decade, new cancer-fighting drugs have been topping $5,000 a month. Only a few of these keep cancer in remission so long that they are, in effect, cures. For most people, the drugs may buy a few months or years. Insurers usually pay if Medicare pays. But some people have lifetime caps and more people are uninsured because of job layoffs in the recession. The nation's new health care law eliminates these lifetime limits for plans that were issued or renewed on Sept. 23 or later.
Celgene Corp.'s Revlimid pill for multiple myeloma, a type of blood cancer, can run as much as $10,000 a month; so can Genentech's Avastin for certain cancers. Now Dendreon Corp.'s Provenge rockets price into a new orbit.
Unlike drugs that people can try for a month or two and keep using only if they keep responding, Provenge is an all-or-nothing $93,000 gamble. It's a one-time treatment to train the immune system to fight prostate tumors, the first so-called "cancer vaccine." Part of why it costs so much is that it's not a pill cranked out in a lab, but a treatment that is individually prepared, using each patient's cells and a protein found on most prostate cancer cells. It is expensive and time-consuming to make.
It's also in short supply, forcing the first rationing of a cancer drug since Taxol and Taxotere were approved 15 years ago. At the University of Texas M.D. Anderson Cancer Center, doctors plan a modified lottery to decide which of its 150 or so eligible patients will be among the two a month it can treat with Provenge. An insurance pre-check is part of the process to ensure they financially qualify for treatment.
"I'm fearful that this will become a drug for people with more resources and less available for people with less resources," said M.D. Anderson's prostate cancer research chief, Dr. Christopher Logothetis.
For other patients on other drugs, money already is affecting care:
—Job losses have led some people to stop taking Gleevec, a $4,500-a-month drug by Novartis AG that keeps certain leukemias and stomach cancers in remission. Three such cases were recently described in the New England Journal of Medicine, and all those patients suffered relapses.
—Retirements are being delayed to preserve insurance coverage of cancer drugs. Holly Reid, 58, an accountant in Novato, Calif., hoped to retire early until she tried cutting back on Gleevec and her cancer recurred. "I'm convinced now I have to take this drug for the rest of my life" and will have to work until eligible for Medicare, she said.
—Lifetime caps on insurance benefits are hitting many patients, and laws are being pushed in dozens of states to get wider coverage of cancer drugs. In Quincy, Mass., 30-year-old grad student Thea Showstack testified for one such law after pharmacists said her first cancer prescription exceeded her student insurance limit. "They said 'OK, that will be $1,900,'" she said. "I was absolutely panicked." The federal health care law forbids such caps on plans issued or renewed Sept. 23 or later.
—Tens of thousands of people are seeking help from drug companies and charities that provide free medicines or cover copays for low-income patients. Genentech's aid to patients has risen in each of the last three years and the company says nearly 85 percent of Americans earn less than $100,000, making them potentially eligible for help if no other programs like Medicaid will pay.
—Doctors and insurers increasingly are doing the cruel math that many cancer patients want to avoid, and questioning how much small improvements in survival are worth. A recent editorial in a medical journal asked whether the extra 11 weeks that Genentech's Herceptin buys for stomach cancer patients justified the $21,500 cost.
Doctors also have questioned the value of Genentech's Tarceva for pancreatic cancer. The $4,000-a-month drug won approval by boosting median survival by a mere 12 days. Here's how to think about this cost: People who added Tarceva to standard chemotherapy lived nearly 6 1/2 months, versus 6 months for those on chemo alone. So the Tarceva folks spent more than $24,000 to get those extra 12 days.
When is a drug considered cost-effective?
The most widely quoted figure is $50,000 for a year of life, "though it has been that for decades — never really adjusted — and not written in stone," said Dr. Harlan Krumholz, a Yale University expert on health care costs.
Many cancer drugs are way over that mark. Estimates of the cost of a year of life gained for lung cancer patients on Erbitux range from $300,000 to as much as $800,000, said Dr. Len Lichtenfeld, the American Cancer Society's deputy chief medical officer.
Higher costs seem to be more accepted for cancer treatment than for other illnesses, but there's no rule on how much is too much, he said.
Insurers usually are the ones to decide, and they typically pay if Medicare pays. Medicare usually pays if the federal Food and Drug Administration has approved the use.
"Insurance sort of isolates you from the cost of health care," and if people lose coverage, they often discover they can't afford their medicines, said Dr. Alan Venook, a cancer specialist at the University of California, San Francisco. He wrote in the New England Journal in August about three of his patients who stopped taking or cut back on Gleevec because of economic hardship.
Two of the three now are getting the drug from its maker, Novartis AG, which like most pharmaceutical companies has a program for low-income patients. About 5,000 patients got help for Gleevec last year, said Novartis spokesman Geoffrey Cook.
"We have seen a steady increase in requests over the past few years" as the economy worsened, he said.
Showstack, whose leukemia was diagnosed last year, gets Gleevec from Novartis. The dose she's on now would cost $50,000 a year.
"I'm not actually sure that I know anyone who could afford it," she said.
Gleevec's cost is easier to justify, many say, because it keeps people alive indefinitely — a virtual cure. About 2,300 Americans died each year of Showstack's form of leukemia before Gleevec came on the market; only 470 did last year.
"I don't think we quibble with a drug that buys people magical quality of life for years," Venook said.
It's unclear whether Provenge will ever do that — it needs to be tested in men with earlier stages of prostate cancer, doctors say. So far, it has only been tried and approved for men with incurable disease who have stopped responding to hormone therapy. On average, it gave them four months more, though for some it extended survival by a year or more.
Until it shows wider promise, enthusiasm will be tepid, said Dr. Elizabeth Plimack a prostate specialist at the Fox Chase Cancer Center in Philadelphia.
"I've not had any patient ask for it," she said. "They ask about it. Based on the information, they think the cost is tremendous, and they think the benefit is very small."
Logothetis, at M.D. Anderson, said Provenge and other experimental cancer vaccines in development need "a national investment" to sort out their potential, starting with Medicare coverage.
"It's no longer a fringe science. This is working," he said. "We need to get it in the door so we can evolve it."
Oct 4, 2010 at 2:10 p.m.
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My Mum has Sarcoma cancer. She is doing chemo and is doing fairly well on it. I asked her about what she would do and she would do anything to live another day. Life is precious and if someone wants to live be it a good last few months or maybe not so good, they should have the right. Until you are faced with this situation, you really don't know what you would do.
Another thing, the insurance companies now are death panels. They are dictating what you can and can't do now. Heck, I want to get a certain test every year but my insurance company is saying NOPE, you can have it every 3 years. It is just them saving money and if you get something in between the testing, no skin of their noses. It is all about the bottom dollar with them.
Sep 29, 2010 at 8:59 a.m.
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These prices are why cancer hasn't been wiped out as a disease. How would the drug companies make money otherwise? Personally, if I were diagnosed with incurable cancer of any kind, I would rather live my last days without drugs or treatment. I've seen the drugs compromise the quality of life for family members only to extend their misery for an additional few months. There is a toll on caregivers having to do everything for a person on these drugs also. JMO
Sep 28, 2010 at 12:22 p.m.
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Callit,
I would like to see data of Oncologists who are battling cancer or cancer survivors themselves to learn whether or not they would advocate chemo. The oncologists and hematologists I know tend to be among the most nihilistic people I've ever met. They deal with death and suffering in a very clinical manner and tend to be numb to the fact that many of their patients die prolonged miserable, painful deaths. But that is life. Not making a judgement call-just my observation.
But more specific to this article, Provenge is not a chemotherapeutic-its a vaccine. This has the opportunity to be a game changer. Furthermore, CMS announced that a coverage decision was expected by March 30, 2011, with a final ruling in June 2011, the net result of this decision will determine whether private insurers cover Provenge as indicated and at its current AWP. There will be very few community oncology practices that want to eat 93K in unreimbursed drug costs. Nor will the NCCN or large academic centers eat this as well. Net effect is that patients that might benefit from Provenge will either be cash payers or foreigners since private insurers tend to follow CMS as a guideline for reimburesement (not all but most do). Professional experience will also determine whether this product is a commercial success. But make no mistake about it that more companies will expand into te ther area of immunotherapeutics because this is where the future profits will lie.
Sep 28, 2010 at 10:40 a.m.
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I agree that we are not sure what the methodology is and it may not pass the P test to be significant, but I can achieve a +(-) 10 percent by surveying 99 of a sample population of 13,000.
This isn't the only "survey" where numbers well over 50% show up under the same line of questioning to oncologists. I do feel from personal experiences in my friends and family that the economic factor is huge in the choice of treating or not treating patients in what will undoubtedly be the last part of their lives.
Sep 28, 2010 at 9:27 a.m.
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Calli,
The data you site is a "survey". It is not statistically powered to produced meaninging results. Its a survery of 128 "cancer doctors" some may actually be board certified medical oncologists. There are approximately 13000 practicing medical oncologists in the United states-to say that 100 would not receive chemo based on survey- would not pass a peer review board as "evidence" let alone would it be considered statistically significant witha p value < .05. The data you site does not show methodology, confidence intervals, let alone the questions asked in the survery-nor are there any standard comparators...again its survey. Substitution coke or pepsi for chemo and you might get the same results. 80% might prefer coke to pepsi
Stage IV pancreatic cancer has very high mortality rates. Ask Randy Pousch or Patrick Swayze. But this does not mean that industry or researchers should not be attempting to reduce the mortality rates through advances in costly medicine such as chemo immunotherapies or monoclonal antibodies. In fact most chemo regimines employ a cocktail of therapies to fight the disease-many are very expensive. Patients refract or relapse because for a variety of reasons-and most importantly patients do not all respond equally to every regimine-despite have the same disease. This is medicine. Its not an exact science.
If a board certified physician, which I am not one, determines with his patient that a specific therapy may have only a 2% chance of being effective-but it may provide 4 months of quality living-this is a decision that is best discussed between patient and physician not government employees reading an acturial table. Conversely, should that same patient not be offered the 2% chance of longer survival or quiality of life even its its for 4 months-there is an attorney ready to sue that physician for malpractice-driving costs even higher.
Sep 28, 2010 at 7:43 a.m.
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Your right phoenix, it wouldn't be an issue. Those drugs wouldn't be available because the "death panel" wouldn't approve it or the drug company would never have developed it.
Sep 28, 2010 at 12:02 a.m.
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The fact that a drug company would market an ineffective and massively expensive drug to provide false hope for the terminally ill is, by itself, profane. The fact that families will willingly hand over their fortunes for a few extra days or weeks with a loved one is sad, but understandable. Life is always more valuable than money, but the drug makers are taking advantage of that sentiment to pad their pockets and those of their stockholders. It is little more than extortion.
Sep 27, 2010 at 11:37 p.m.
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Say what you will, but if the USA caught up with the rest of the industrial countries of the world and we had Univeral Health Care, price tags like that one would not even be an issue.
Sep 27, 2010 at 11:11 p.m.
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Not a blanket claim TCB, I said I would make sure it was effective for the type and stage. Final stage for most, such as pancreatic, no thanks. Some are given chemo by there providers although it is less than 2 percent effective. As for the statistics, 128 is a meaningful sample and 80 percent makes it even more so. At least that is what I was taught on graduate school.
Sep 27, 2010 at 6:10 p.m.
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Callit
While 80% of the 128 oncologists is too small a sample size to be meaningful or statistically significant less than .5% of all practicing oncologists-100% of those surveyed earn significant incomes prescribing infused chemotherapuetics.
How can you make a blanket claim that living with cancer is bette than treating the disease? The side effects for many chemos are very benign and for many cancers if caught early have very good remission rates.
Sep 27, 2010 at 4:19 p.m.
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ill be there for that pain management mr kraut;)
Sep 27, 2010 at 2:56 p.m.
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Bob Svensson got the smile of "hey I can do this and there nothing you can do about it"
Sep 27, 2010 at 2:41 p.m.
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For me, adding a couple of months wouldn't be worth $10,000 much less $93,000. Of course my opinion has been jaded by seeing too many people put through the rigors of chemo with no results. I would not undergo the treatment unless I was sure it was effective for my condition.
In a survey of 128 cancer doctors 80% said they wouldn't take chemotherapy. The truth is it works well only on some cancers at certain stages and the side effects are worse than living your life out without it.
http://www.canceractive.com/cancer-activ...
Sep 27, 2010 at 1:24 p.m.
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Provenge is indicated for asymptomatic or minimally symptomatic metastatic castrate resistant prostate cancer-a relatively rare disease. When another firm decides to invest $1+ billion of its capital into this market space-and when it generates data that improve/increase overall survival compared to current and convential therapies-the price of provenge will decrease.
Simple economics.
Calli-has it correct. 50% of the healthcare dollar is spent on the last 6 months of life. The real question is do you as a patient want the same type of person who works at the DMV to determine whether you are eligible for a therapy like provenge? Or would you prefer your physician to help guide your decision? You decide.
Lower health-related quality-of-life (HRQoL) index scores may keep Provenge from ever being added to the NHS (United Kingdom) national formularyor the candian national formulary-due to cost. But those with means ($$) will still be eligible for this product-guess where the canadians will go? Physicians will continue to prescribe Avastin for brain cancer (100K+) or Revilimid for multiple myeloma dispite poor outcomes. Stem cell transplants cost 250K+ and are often considered last resort actions-patients young and old have suffered and cost the healthcare systems millions before dying. Before you are quick to castigate anyone trying provenge-consider that death is the price we all pay for life. If Provenge is too expensive-what else is too expensive?
Sep 27, 2010 at 12:06 p.m.
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The truth is a major portion of medicare funds are spent in the last days of the recipients life as heroic measures are tried on elderly patients who should be left to die in dignity versus padding the pockets of hospitals and doctors. This treatment shouldn't be covered by medicare or private insurance in my opinion.
Dying is a part of life and every one's time is coming. Accept it with grace.
Sep 27, 2010 at 11:16 a.m.
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There is nothing political about this, and conversations about death panels to add fear to the conversation are worthless. It's my opinion that the patient also has a moral obligation in this debate. An 80 year receiving $93K for 4 more months? I would not ask that of my grand kids. Bob Svensson is a coward if you ask me.
Sep 27, 2010 at 10:42 a.m.
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If the govt decides that the price of certain drugs is not worth a few extra months of your life, then that is a death warrant signed by the govt.In England they refuse to treat some breast cancer patients because of the cost to the health care system. Certainly a death panel.there is nothing in these drugs that warrant the high cost. The Drug companies want recovery costs for R&D, even tack it on for drugs that fail.What we need is control of drug prices to a more reasonable level.Drug co's want fast recovery and profit.
Sep 27, 2010 at 10:38 a.m.
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I think that the patient best answered the question. He would not spend the money, but would gladly allow someone else to do so.
Sep 27, 2010 at 10:13 a.m.
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"His supplemental Medicare plan is paying while the government decides whether basic Medicare will cover Provenge and for whom."
Does not sound private insurance company to me. Does sound suspiciously 'death panel'
Sep 27, 2010 at 9:46 a.m.
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This is not the Health Care Reform bill's "death panels". Don't be silly. The government is not making these decisions, private health insurers are. For a long time the only death panels have been in the profit and loss statements of insurance companies.
Sep 27, 2010 at 9:09 a.m.
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This report is for those who were laughing about the "death panels" in the discussion about Obama-care before it became law. "...how much a few months more of life is worth."
Just wait when Obama-care finally kicks in to full effect. This report shows how close it is to your new reality.
Sep 27, 2010 at 8:17 a.m.
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Run From The Cure....
http://www.youtube.com/watch?v=0psJhQHk_...
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