As many of the Republican and Democratic presidential candidates lament the high cost of healthcare and put forth how they aim to make it more cost effective, few have focused on the impact of out-of-pocket costs specifically for cancer patients. They should. One in every two men and one in every three women will get cancer at some point over their lifetime. As the U.S. population and American lifespans increase, this toll will have major financial ramification for everyone.
When fighting against the disease, cancer patients are often at the mercy of the pharmaceutical industry. Given Pfizer’s recent announcement that it plans to merge with Allergan, making it the largest pharmaceutical company in the world, many cancer patients are wondering what this will mean in terms of their cost of care. Pfizer, a giant in the cancer pharma space, already raised prices on 133 of its brand-name drugs last year, and they are not alone. Big pharma has raised cancer drug prices up to 5000%. Recently ousted Turing CEO Martin Shkreli justified such hikes explaining, “I could have raised [prices] higher and made more profits for our shareholders, which is my primary duty.” The lack of focus on patients spawned outrage amongst patients, providers and even politicians, but the drug industry seems to be “in denial of the seriousness of its pricing problem.”
Granted, drug production takes years of research and can cost $350 million to get a single drug to market. Considering 95% of the experimental drugs will never see a pharmacy shelf, it might seem reasonable that the cost to patients is on the increase. But contrary to the pharmaceutical industry’s claims, the cost of innovation is not the driver of drug prices. A study published in JAMA Oncology found that prices of cancer drugs are not tied to novelty nor to effectiveness, but rather set to what the market can bear. Here within lies the problem: if you’re a patient faced with a cancer diagnosis, wouldn’t you pay whatever the cost, no matter the price?
Indeed, many cancer drugs now cost more than the average household income, and prices of over $100,000 per year are common. It is no wonder that medical costs remain the leading reason for bankruptcy filings in this country. But skyrocketing costs don’t just affect patients’ pocketbooks; they also affect their well-being. In a national study of over 2100 cancer survivors, we found that the financial burden associated with cancer care was the leading factor affecting patients’ quality of life. Survivors who said they had “a lot” of financial difficulties associated with their cancer care were four times more likely to report having a poor quality of life than those who reported no financial issues, controlling for other factors including age, race, education, insurance, family income, and cancer type.
As physicians who aim to improve the quantity and quality of patients’ lives, we have a duty to minimize the financial toxicity our patients face. Yet our options for doing so often seem limited since we don’t set drug prices. Some doctors have made use of websites like www.drugabacus.org which help them understand the actual cost and value of any cancer drug, to determine whether to prescribe any one particular drug. Others have made use of generic substitutes, but these cheaper alternatives are not always available. For example, the $10,000-a-month drug Gleevec (imatinib mesylate) used to treat chronic myeloid leukemia has been around since 2003, but FDA approval of the generic equivalent was just granted. Still others use novel tests that, while costly themselves, can predict whether toxic (and expensive) medications are truly beneficial.
In his final State of the Union address, President Obama called for a “moon shot” to cure cancer. While most of the efforts of this ambitious project will focus on the biology of the disease, containing the cost to patients must also be part of the agenda. The National Cancer Institute estimates that our annual expenditure on cancer care will rise from $125 billion in 2010 to over $156 billion in 2020. If we are to contain costs, we as a society must not only depend on expensive high tech and novel therapeutics. Take for example, the long-term data from a randomized controlled trial that found that low fat diet was associated with a 54% reduction in mortality in patients with hormone receptor negative breast cancer (which is often associated with a poor prognosis). If these data were the result of a new drug, it would be widely prescribed at any cost. Yet, few physicians write prescriptions for “low fat diet” which yielded these results.
Similarly, when my colleagues and I published the findings of our randomized controlled trial that showed removing a little more tissue during initial surgery could save thousands of breast cancer patients the need for a second operation, a colleague of mine lamented that we could not package this technique and sell it since many companies are developing sophisticated and pricey devices to try to achieve the same results. As breast cancer experts gathered in San Antonio for our annual meeting last month, I presented data on how we achieved these outcomes without capital equipment and without increasing costs. True, I won’t get rich. But by helping to bend the ever-increasing cost curve, I may improve the lives of our patients. And isn’t that really why we’re in this business to begin with?
Anees Chagpar is a Yale associate professor of surgery and Director of The Breast Center — Smilow Cancer Hospital at Yale-New Haven. Follow her @AneesChagpar