Dr. Nagourney's Blog

The Cost of Care for Stage 4 Colon Cancer: How Much is Too Much?

By Robert A. Nagourney, MD

Among the most important topics of discussion at cancer meetings today is the cost of cancer care.

Terms like “financial toxicity” are used to describe the growing out-of-pocket and institutional expenses associated with the use of advanced therapies. 

A Look At One of the Colorectal Cancer Treatment Options - Bevacizumab

One example is the monoclonal antibody Bevacizumab that is widely used in metastatic (Stage 4) colorectal cancer.

A recent study examined the cost effectiveness of Bevacizumab in that disease. (Goldstein DA Bevacizumab for metastatic colorectal cancer: A global cost-effectiveness analysis. The Oncologist, 2107;22;694-699)

In 2017, the standard treatment for metastatic colorectal cancer consists of either FOLFOX (US) or FOLFIRI (Europe) combined with Bevacizumab.

Over years of investigation, these combinations have established survival benefit for the treatment of metastatic disease leading them to become the “gold standards”.

Despite the recognized benefit, Bevacizumab’s addition comes at a cost. The authors of this study wanted to determine the return on investment that Bevacizumab provides in terms of lives saved.

Analyzing the Cost of Cancer Care 

They used what is described as quality adjusted life years (QALYs) and applied a tool known as the incremental cost effectiveness ratio (ICER).

These pharmacoeconomic tools are well known and widely used in cost analyses of cancer care.

In the Western world today it is considered a worthwhile investment if a patient’s life can be extended by one year at a cost not exceeding $100,000. That is, one quality adjusted life year (QALY) should come in at about $100,000.

The authors included patients from the US, UK, Canada, Australia, and Israel to assess the impact of Bevacizumab-based therapy on survival and the cost to achieve that survival benefit.

Is Bevacizumab Really Cost Effective?

They found that the addition of Bevacizumab for first line therapy of metastatic colorectal cancer provided 0.1 QALYs.

That is 1/10th of a patient year provided by the wide scale use of Bevacizumab.

When they applied ICER analysis, the current use of Bevacizumab came to a whopping $571,000/QALY, just over 5.7 times the current standard. Although prices varied from country to country, with Australia falling below and the U.S. falling above the average, the results exceeded the accepted QALY norms in all countries examined.   

What this study brings into disturbing focus is the problem with the indiscriminate use of extremely expensive drugs for limited return.

Bevacizumab is one of the most expensive drugs used in cancer therapy.

Although it offers real benefit for patients whose tumors are driven by vascular endothelial growth factor (VEGF) it is not universally effective for any disease. While it has shown efficacy in lung, colorectal, ovarian, renal and other cancers, the problem we confront is knowing who to give it to, and when to give it.

At face value, this analysis finds that Bevacizumab is simply not cost effective.

A logical extension might be that at some point in the future, insurers will decline coverage.

This raises serious concerns regarding the affordability of cancer care in an aging population for whom cancer will soon be the leading cause of death. While Bevacizumab is the subject of this investigation, there is nothing unique about this drug, as the majority of drugs approved by the FDA for cancer since 2012 have price tags above $10,000/month.

A Point to Consider 

How do we address this dilemma?

It seems obvious that the appropriate selection of treatment candidates will be the only way out.

We must use models that enable us to select patients who are most likely to respond to treatment.

The failure to apply validated laboratory platforms and the unwillingness of the oncology community to adopt these approaches could soon come back to haunt practitioners all over the world.

Squandering the opportunity to take-the-lead and use treatments judiciously, physicians may find themselves closed out of the decision making process altogether. We are entering an era when treatments are approved not only for safety and efficacy, but for cost-efficacy and government and insurance policies can prove rather hard-edged.

The oncology community would do well to re-visit laboratory models that qualify treatment candidates before they receive expensive drugs. By failing to do so, physicians and their patients may find themselves on the wrong side of rationing and denial of care.  

As always, I appreciate your thoughts and comments.

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