We practice too much marginal medicine – interventions that are not ineffective, but offer minimal benefits for their cost.[1] One particularly disturbing example is Erbitux (cetuximab) of ImClone fame – the stock that landed Martha Stewart in jail. Erbitux is a monoclonal antibody that targets the epidermal growth factor receptor. It is used alone or in combination with irinotecan for patients with metastatic colon cancer. Treatment is purely palliative; no patient is ever cured. Erbitux isn't even first-line therapy. Randomized studies show that when used as second-line therapy, Erbitux extends life an average of only 1.7 months.[2] The cost for the first 8 weeks of treatment is more than $30,000 per patient.[3] If the 50,000 Americans per year who die of colorectal cancer were treated with Erbitux and irinotecan, the cost would exceed $1 billion just for the drugs, not counting lab tests, physician fees, and antinausea drugs.[3] Private insurance, Medicare, and Medicaid should not pay for drug treatments like Erbitux. If an individual wants to pay that much for so little benefit, so be it.
Other prime examples of wasteful marginal medicine include lung volume reduction surgery for emphysema, antitumor necrosis factor drugs for rheumatoid arthritis, Macugen for macular degeneration, implantable defibrillators, and CT [computed tomographic] scans for the detection of heart disease.
Some say that spending on marginal medical care doesn't hurt anything. Not true if the payment comes from public funds or insurance. States are cutting public education and raising tuition at state universities because of rising Medicaid costs. Employers are cutting insurance for retirees and employees. Rising medical costs help create so many uninsured Americans.
We doctors need to be more responsible in how we practice. We need to work toward eliminating marginal medical care and using interventions with more tangible benefits.[4,5] This way we can really promote health, cover more uninsured, and improve education – which itself greatly improves health.
That's my opinion. I'm Dr. Ezekiel Emanuel, Department of Clinical Bioethics, the National Institutes of Health.
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References
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