Posted: October 10, 2016

Physicians in training are deeply schooled in evidence-based medicine: do what works, know the basis of what you decide to do for your patients.  A corollary of practicing evidence-based medicine is practicing cost-effective medicine: only spend money if the patient has a decent chance of benefiting from the intervention — either diagnostic or therapeutic.  Do we ration care on this basis in the United States today?  If not should we, considering that resources are not infinite?  The Institute for Clinical and Economic Review is about to publish an exhaustive analysis of the cost benefit ratio of the treatment of non-small-cell lung cancer.   This analysis can be accessed through this link and downloaded in full if you wish.Those of you familiar with this field are aware of two recent important developments: first, with an understanding of the role of cancer-associated mutations (seen only in the cancer cell, not in other bodily cells) new drugs have been developed that target these mutations, providing longer remissions than ever seen with chemotherapy, and without most of the side effects; and second, these drugs are wildly expensive, costing typically $10-20,000/month.  Even if insurance pays most of this the patient can be left with a co-pay of several thousand dollars a month.

The authors popularize a term just gaining a toehold in oncologic circles: “financial toxicity.”  In addition to nausea, hair loss and a drop in blood counts, cancer drugs can bankrupt a patient and, equally importantly, his survivors.  So how much financial toxicity is too much, and is there anything we as a society can do about this?

Dr. Stark weighs in, “I never want to be put in a position of protecting the overall cost of health care by depriving a patient of an expensive drug that I knew was not curative and might not even work.  My view is that I work for the patient, not the system.  But somebody needs to work for the system — not the care giver for sure.  The pejorative term ‘death panels’ has been used regarding the attempts of organize medicine to control costs; taking the politics out of it, we as a society must decide what an extra month of life is worth, and who will pay for that month.  We should decide whether the government or the insurance agency should cap what companies can legally charge.  We should also decide whether a perk of extreme wealth is the possibility of circumventing whatever cost controls are put in place.  The article cited herein is a rational start to this discussion.”

Update 2020: the cost of cancer drugs is only going up.  The latest therapy for advanced metastatic disease — CAR-T-cell therapy — costs about $400,000 per patient.  It involves taking a patient’s white blood cells and incubating them in the laboratory to produce a cancer-killing cocktail.  It is labor intensive but when it works the results can be curative.  As a society we continue to dodge the question of what is a life worth?  CAR-T-cells have reframed the question.