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QUALITY/POLICY/PHARMA: More on the costs of chemo

So the fight over cancer drug reimbursement is getting quite nasty. The doctors, who as we’ve explained in TCHB many times, have done very well over the last decade or so by dispensing drugs and charging Medicare and private payers a whopping margin, are crying foul as the details of the current price cutting by CMS emerge. Apparently they believe that the overall cut will be 15% as opposed to CMS’s stated 8%. There’s much more in this AP Article.

There’s actually some real money at stake here. About $600m is being cut from the chemo drug budget. ASCO claims 20,000 members but my mole in the business tells me that there are somewhere around 10,000 oncologists (or docs dispensing enough chemo to be counted as oncologists) in the US with an average income in the high-$300,000s of which roughly half comes from the drug mark-up. So you could argue that actually 30% of the doctors’ drug income (i.e. their margins rather than total drug spending) or around $60,000 per physician, is on the table. So expect the fight to continue, and of course have ramifications downstream on the pharma companies, and upstream on the patients.

Meanwhile, back on the subject of chemo, Harvey Fry writes concerning the post last week by Greg Pawelski on chemosensitivity testing.

I fought for chemo-sensitivity testing of cancers over 20 years ago, and finally lost because of the problems with the tests. First, it’s often hard to get a representative sample of tumor cells by biopsy. Then it’s hard to get them to grow. Then you’re not sure whether the cells that grew out are the tumor cells, or normal matrix, like fibroblasts. Then there’s the delay in starting treatment while waiting for the cells to grow out. Then there’s the question of whether cells in metastases have the same response as those in the primary. But the killer was that the clinical response was not that well predicted by the cell survival tests in the lab. And of course, there was the expense.

Unless there has been some major advance in the intervening years, I can understand the reluctance of some oncologists to go back to it. Alternatives to growing the cells and seeing what kills them may now exist, but they are only surrogates for the real end-point of interest.

Sidebar: I was struck by an amusing wrinkle in the end of the chemo article which showed how close the two sides are politically, even if they are fighting over money:

Ketchum Communications, the public relations company working with the cancer doctors to call for a change in the Medicare law, also is the principal contractor employed by the administration to promote that same law. The administration has spent $87 million on television ads, mailings and other means to promote the new law, most of it to tout prescription drug coverage that will be available through Medicare in 2006, the Health and Human Services Department said.

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Gregory D. Pawelski
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Gregory D. Pawelski

Medicare Coverage for Cell Culture Assay Test A genomic test can help to find out if a cancer patient will benefit from chemotherapy or not, and if they do (high risk patients), further pre-tests like cell culture assays can help see what treatments have the best opportunity of being successful. A cell culture assay measures the response of the tumor cells to drug exposure. Following this exposure, one of these assays measures both cell metabolism and cell morphology (Whole Cell Profiling). The integrated effect of the drugs on the whole cell, resulting in a cellular response to the drug, measuring… Read more »

Gregory D. Pawelski
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Gregory D. Pawelski

NCI’s Failure at assay-directed therapy NCI studies never determine if “fresh” tumor assays worked. All of the considerable literature which supports the use of these assays in patient management has been based on true “fresh” tumor (non-passaged) cell assays. Some years ago, NCI made an attempt to study “assay-directed” therapy of lung cancer. The study was a failure because it was done with established permanent cell lines (instead of fresh cells), which have been conclusively proven to have no predictive value at all with respect to the clinical activity spectrum. The result was a dismal 11% response. The NCI used… Read more »

Gregory D. Pawelski
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Gregory D. Pawelski

Public Interest Watch had called for a government investigation into ASCO, for the manipulative ways in which it had attempted to scuttle badly-needed reforms in this inherently corrupt system. An Associated Press account of maneuverings by ASCO in its attempts to preserve its lucrative chemotherapy concession, stated that Public Interest Watch called on the U.S. Department of Health and Human Services have a formal investigation of its contract with Ketchum Communications to promote reforms to Medicare. According to Associated Press, Ketchum was Health and Human Services principal contractor in its $87 million public campaign to gain acceptance of changes to… Read more »