Cancer: Are we making progress?
A line in an article I was reading the other day gave me pause: “The age-adjusted mortality rate for cancer is essentially unchanged over the past half-century, at about 200 deaths per 100,000 people.”
Could this be true? If so, it made me wonder if—with all our state-of-the-art technologies, advanced medicines, and decades’ worth of garnered wisdom—we were truly no better off today than the day I was born in 1966.
It turns out that the statistic was correct. For 50 years, rates of cancer mortalities have essentially been (excuse the pun) flat-lined. But statistics are often misleading.
Since the early ‘90s, those rates have been on the decline. In 1990 the death rate for cancer was 200.8 per 100,000 people. In 2012: 166.5 deaths per 100,000 people. This amounts to a 17% decrease. Moreover, from 1990 to 2010 the 5-year survival rate for all cancers increased by 12%. Not only that, just over half of Americans in 1990 lived at least five years after their diagnosis; now that number stands at two-thirds.
All of which is good news. From a purely numbers standpoint things have definitely taken a turn for the better. But there’s more to it than that.
Life expectancy has increased all the while, and, with that, the risk of being diagnosed with cancer has followed suit. A cancer diagnosis is in the cards for almost 50% of the male population and one-third of women. So, while the good news is that cancer survival rates have risen, the bad news is that cancer prevalence has as well.
With cancer more widespread than ever before it only stands to reason that expenditures on it have too. $27 billion (adjusted U.S. direct medical spending) was spent on cancer in 1990. By 2010 that number rose to $124.6 billion, an increase well over 350%. Of that cost, the Agency for Healthcare Research and Quality (AHRQ) reported in 2011 that approximately 11% goes toward prescription drugs.
According to an article published by the Mayo Clinic, “the average price of new cancer drugs increased 5- to 10-fold over 15 years, to more than $100,000 per year in 2012.” Notably, during that same time-frame U.S. household income decreased by roughly 8%. Cancer patients and their families would tell you that it’s worth the financial hardship to benefit from the greater health outcomes that these new drugs provide. That statement assumes two things: 1. New drugs provide greater outcomes; and 2. Those outcomes are worth the cost. Let’s explore that.
First, consider Abraxane. It came on the market to compete with paclitaxel, an older generic drug. Abraxane costs roughly $10,000 per dose. Paclitaxel, $200. Essentially, they both do the same thing. The outcome is not greater, though the cost certainly is. Same with Zaltrap. A competitor against the older bowel cancer treatment, Avastin, it costs approximately $11,000 a month. Avastin, $5,000. Similar drugs. Similar outcomes. Huge price discrepancies.
Abraxane and Zaltrap are just two examples of a disturbing incongruity in our drug pricing system: price does not necessarily reflect efficacy. In other words, just because one drug is more the more expensive than a competitor, it doesn’t mean it is more effective.
Of course, some new drugs definitely provide better outcomes. The question then is whether the outcomes are worth the price. A typical chemotherapy regimen for non-small cell lung cancer extends a patient’s life by an average of just two months. It also costs more than $40,000. In the case of breast cancer there is a treatment regimen that extends survival by an astounding 16 months. Unfortunately, the price tag for those precious months can easily exceed $100,000.
To their credit, oncologists are well aware of the issue of costs vs. benefits. The drugs that have little or no real benefit to their patients, especially in light of their exorbitant prices, they are no longer prescribing. This is a remarkable change from years past where the principle mind-set was to extend life at all costs. Feeding into this turn-around is that physicians & patients are no longer confusing statistical significance with practical significance. Yes, drugs are letting patients live longer, but often it’s simply not worth the cost with regard to the (lack of) quality of life it affords.
That bring us to the raw costs of cancer medicines. Whereas a decade ago cancer drugs generally provided an extra year of life for less than $100,000, most new treatments typically cost up to $200,000. Worse still, cancer patients and their families have to shoulder most of the financial burden as insurers have resorted to place these high-priced medications into “tiers” that necessitate higher out-of-pocket costs. Insurance companies balk that things would be different if pharmaceutical manufacturers charged fair & reasonable amounts for their drugs. Reps for the Pharma industry retort that insurers lack transparency in their medical plans and unreasonably shift more costs onto their consumers. As usual, the patient is the one stuck in the middle.
Curiously, drugs are not that panacea we all think. Richard Sullivan, director at King’s College London’s Institute of Cancer Policy, says that pharmaceuticals make up only 4-5% of total improvements in outcomes. Surgery and radiation therapy (RT) have the most positive therapeutic effects. Out of a hundred patients, chances are chemo may not work for 90 of them. Yet one cannot dismiss chemotherapy out of hand. You can scoff at a 90% failure rate, but those 10 cancer patients who are now alive & well might beg to differ.
So has progress been made?
The macro view at overall cancer survival and mortality rates shows that is the case. But, as with all things, the devil is in the details. Between 1990 and 2006 a 40 percent decrease in the overall cancer mortality rate in men was the direct result of the reduction in lung cancer. A major factor contributing to this was not better medications but that men simply stopped smoking. The important lesson here is that while drugs do offer benefits, there are other non-pharmaceutical avenues—diet, behaviors, and environmental conditions—that may produce positive results as well. Progress in unexpected places is still progress.
Though pharmaceutical manufacturers are devoting time, resources, and money to new cancer-fighting drugs, their costs to consumers are rising at an ever-increasing pace. These new drugs must be closely monitored to ascertain their benefits vis-à-vis older, less expensive medications. Physicians are now taking a hard look at that. Drugs’ cost effectiveness must be determined as well. To that end a “net health benefit” (NHB) score has been recently established. (Analysts take two drug regimens and assess their overall survival, response rates, and comparative toxicities with respect to their costs.) That’s progress.
Tough choices must be made with regard to medicines’ true efficacy. Is it worth potential bankruptcy for a cancer patient to gain mere months, or even weeks, of life? And what about quality of life during that time? Both questions weigh heavily in a family’s decision-making process. Time was that we ignored the unasked questions because it was too terrible to contemplate. Families across the U.S. are now starting those conversations as early as possible to allay some of those fears. The next step is for regulatory agencies, insurance companies, government administers, and even the pharma companies themselves to drive down costs of these life-saving medicines, especially for the poor who cannot afford them, so that these questions & conversations become moot. Progress yet to be attained.