While medical oncologists, drug developers, and research scientists presented their research findings and novel treatment options in hematological cancers, a special session in the afternoon on the first day of the 56th
Annual Meeting of the American Society of Hematology (ASH), held December 6 to 9 in San Francisco, addressed an aspect of cancer care that’s increasingly finding its way into the mainstream healthcare discussion at clinical meetings. This was seen at the annual meeting of the American Society of Clinical Oncology
(ASCO) earlier this year. The session, “The rising cost of medical care: understanding the problem and exploring solutions,” saw participation by hematologists and a representative from a company that provides market access support to the pharmaceutical industry. These experts came together on a common platform to identify ways and means to tame the unsustainable healthcare expenditure in the United States, which touched $3.8 trillion in 2013.1
Rising drug costs can influence patient adherence, quality of life, and overall health—an endless loop. Participants in this energetic discussion provided insight into these existing challenges and means to address them.
Kicking off the session was Hagop M. Kantarjian, MD, professor, Department of Leukemia, the University of Texas MD Anderson Cancer Center, Houston. Kantarjian provided very strong opinions against drug pricing by the pharmaceutical industry during his talk, “Cancer drug prices in the US: causes, consequences and solutions.” He said he is surprised by the high drug prices today—the trigger for him were 3 commonly used drugs for chronic myelogenous leukemia: ponabinostat, bosutinib, and omacetaxine. All 3 drugs cost more than $100,000 per year.
While cancer drug prices have been rapidly rising—a 10-fold increase over a decade—the average household income, he said, has decreased by 8%. Kantarjian asked the audience to come up with solutions to help these patients who might be victimized in the process. High out-of-pocket costs, he said, are leading patients to personal bankruptcy, adherence issues, and mental stress; results show that 10% of patients abandon treatment and 20% have poor compliance.
Kantarjian came down hard on the pharmaceutical industry for overestimating the amount spent on developing a drug, “ The billion dollar price tag per drug does not account for 50% tax subsidy that they avail, and it’s the mean cost not median.” He concluded his talk by providing several solutions:
increased/continued participation by organizations like ASCO and ASH in the discussion
Medicare should be allowed to negotiate the price of drugs they buy from pharma
allow import of drugs
prevent “pay-for-delay,” which blocks all other generic drug competition for a growing number of branded drugs.
Providing nearly a contradictory opinion was Alex W. Bastian, MBA, vice president, Market Access, GfK Bridgehead. During his talk, “Hematology drug pricing in America: moving to a sustainable model,” Bastian acknowledged that while the unsustainable drug cost cannot be ignored, we need to focus our attention on value of therapy rather than cost, which echoed the ASCO initiative. Bastian went on to emphasize though that the US is not isolated with this problem; rising healthcare costs are a global phenomenon.
He presented the real-world situation; with the success of innovation and research, dramatic survival gains have been achieved in hematology over the past half century, he said. However, if you look at the statistics, while FDA-approved drugs have steadily increased between 1998 and 2014, 249 hematology drugs have failed during the same period. These failures, according to Bastian, need to be accounted for.
He reiterated the importance of identifying the value of therapy. “We need a long-term view of the situation, taking into consideration the total benefits that a drug might yield,” which can prevent downstream cost of care.
Another member of the panel, S. Yousuf Zafar, MD, MHS, associate professor of medicine at Duke University, presented his thoughts next. Zafar, a medical oncologist by training, is a health service researcher with an interest in improving care delivery for advanced cancer patients. His research focus includes studying the impact of cost of cancer care on patient preferences with cost-related communication and decision-making.2
Zafar also alluded to the substantial financial burden of the high cost of care on cancer patients and survivors that can impair their quality of life and diminish the quality of their cancer care. He said that coupled with chemotherapy side-effects, cancer treatment can be financially toxic. A study published last year from Fred Hutchison Cancer Center found that people diagnosed with cancer are more than 2.5 times likely to declare bankruptcy than those without cancer.3
Zafar eluded to the fact that financial toxicity can also impact quality of care as patients are at risk for cost-related nonadherence with their anticancer therapy; studies have demonstrated decreased adherence to tyrosine kinase inhibitors in patients with chronic myeloid leukemia, he said.
Zafar used a case study of a patient in his clinic. He made a case that his patient lacked prescription drug benefit through his employer, which resulted in him refusing advanced therapy when his cancer came back and had metastasized. The patient told Zafar that he could simply not afford to pay for the treatment. Using this paradigm, Zafar suggested that physicians, patients, and policymakers face a growing mandate to integrate costs into clinical decision-making, he said.
However, little is known about patients’ preferences for incorporating cost discussions into cancer treatment decision-making, and little is known about the ramifications of those discussions. Zafar’s research group conducted a prospective, longitudinal study to determine if patients wanted to discuss the costs of treatment with doctors, if patients wanted to incorporate costs into treatment decision-making, and if patients found cost discussions useful in lowering out-of-pocket expenses. Of 300 patients surveyed (86% response rate), 52% expressed some desire to discuss treatment-related out-of-pocket costs with their doctor, and 51% wanted their doctor to take costs into account to some degree when making treatment decisions. Only 19% had talked to their doctor about costs. Of those, 57% reported lower out-of-pocket costs as a result of cost discussions. Hence, cancer patients varied in their desire to discuss costs with doctors, but most who discussed costs with doctors believed the conversations helped reduce their expenses.
“Our study highlights that patient-physician cost communication can reduce out-of-pocket costs even in oncology where treatment options are often limited,” he said. While heterogeneity was observed among patients with respect to preferences on cost discussion, a significant number of those who broached the topic found help in reducing their expenses despite well-described barriers to effective cost discussions, concluded Zafar.
You can hear our exclusive interview with S. Yousuf Zafar, MD, MHS, on AJMCtv
Munro D. Annual U.S. healthcare spending hits $3.8 trillion. Forbes website. http://www.forbes.com/sites/danmunro/2014/02/02/annual-u-s-healthcare-spending-hits-3-8-trillion/. Published February 2, 2014. Accessed December 6, 2014.
Duke Department of Medicine website. http://medicine.duke.edu/faculty/details/0373417. Accessed December 4, 2014.
Cancer diagnosis puts people at greater risk for bankruptcy [press release]. Seattle, WA: Fred Hutch; May 15, 2013. http://www.fredhutch.org/en/news/releases/2013/05/cancer-diagnosis-greater-risk-bankruptcy.html.
St. Michael’s hospital website. http://www.stmichaelshospital.com/research/profile.php?id=laupacis&. Accessed December 4, 2014.