How much is life worth? The $440 billion question

Jun 29, 2009

The decision to use expensive cancer therapies that typically produce only a relatively short extension of survival is a serious ethical dilemma in the U.S. that needs to be addressed by the oncology community, according to a commentary published online June 29 in the Journal of the National Cancer Institute.

Tito Fojo, M.D., Ph.D., of the Medical Oncology Branch, Center of Cancer Research at the National Cancer Institute, in Bethesda, Md., and Christine Grady, Ph.D., of the Department of Bioethics, the Clinical Center at the National Institutes of Health, tackle the controversy concerning the life-extending benefits of certain and the extent to which their cost should factor in deliberations.

The authors illustrate cost-benefit relationships for several cancer drugs, including cetuximab for treatment of non-small cell lung cancer, touted as "practice changing" and new standards of care by professional societies, including the American Society of Clinical Oncology.

They ask, "Is an additional 1.7 months [the additional overall survival for colorectal cancer patients treated with cetuximab] a benefit regardless of costs and side effects?"

According to Fojo and Grady, in the U.S., 18 weeks of cetuximab treatment for non-small cell lung cancer, which was found to extend life by 1.2 months, costs an average of $80,000, which translates into an expenditure of $800,000 to prolong the life of one patient by 1 year. At this rate, it would cost $440 billion annually, an amount 100 times NCI's budget, to extend the lives of 550,000 Americans who die of cancer annually by 1 year.

To address the issue, the commentators recommend that studies powered to detect a survival advantage of two months or less should test only interventions that can be marketed at a cost of less than $20,000 for a course of treatment.

Every life is of infinite value, the authors say, but spiraling costs of cancer care makes this dilemma inescapable.

"The current situation cannot continue. We cannot ignore the cumulative costs of the tests and treatments we recommend and prescribe. As the agents of change, professional societies, including their academic and practicing oncologist members, must lead the way," the authors write. "The time to start is now."

More information: Fojo T. and Grady C. How Much Is Life Worth: Cetuximab, Non - Small Cell , and the $440 Billion Question J Natl Cancer Inst 2009, 101: 1-5.

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pcunix
not rated yet Jun 29, 2009
I think something like that (indexed for inflation, of course) makes sense.

I'd like to see those who can afford more pay a "medical tax" that would go toward research to make these procedures cheaper and available to more people.
gdpawel
not rated yet Jul 01, 2009
The era of personalized medicine based on validated biomarkers is at hand. As the increasing numbers and types of cancer drugs are developed, oncologists become more and more likely to misuse them in their practice. Developing a good and clinically practical drug selection system is no less important than the discovery of new drugs or how to put them into the body.

The needed change in the 'war on cancer' will not be on the types of drugs being developed, but on the understanding of the drugs we have. The system is overloaded with drugs and underloaded with the wisdom and expertise for using them.

The single most neglected area of cancer research has been the development of methods and technologies to be matchmakers between individual cancer with individual cancer treatment. The single most neglected area of cancer treatment has been the unwillingness to utilize the matchmaker technologies which have already been developed and which are already available.

Two years ago, three federal agencies, NCI, FDA, and CMS, announced their program to try to identify biological indicators, or biomarkers, which may indicate whether a cancer patient is likely to benefit from a given anti-cancer therapy, or even whether they will suffer from certain side effects. Biomarkers were already a part of drug development, but health officials wanted to routinely incorporate those measurements into clinical trials.

We have the biomarkers for who will respond so we don't give these powerful and expensive medicines to those who won't. Just look at the Iressa/Tarceva story. A total failure of huge clinical trials because the proper patients were not selected. We should be able to detect cancer pathways with biomarkers and choose patients for a trial based on who responds very quickly to a drug. The ordinary trial system will not suffice if we are to encourage new drugs for restricted numbers of patients.

The methods of cancer medicine during the last thirty some years are coming to haunt the "one-size-fits-all" establishment. Technologies, developed over the last twenty years by private researchers, hold the key to solving some of the problems confronting a healthcare system that is seeking ways to best allocate available resources while accomplishing the critical task of matching individual patients with the treatments most likely to benefit them.