Abstract
As the BMA calls for a royal commission to consider copayments for cancer drugs in the UK, Fred Charatan looks at the problem in the US
The high cost of anticancer drugs is posing serious problems for patients and doctors in the United States. Even patients who are insured face difficulties because of the expense of copayments.
The American Cancer Society said that the cost of cancer care in the US rose by 25% between 2004 and 2007, from $72bn to $89bn (£45bn; €56bn), partly because of the increased cost of drugs.
The American Society of Clinical Oncology is so concerned about the cost of drugs that it has set up a task force to help doctors discuss costs with patients. It is expected to report this autumn.
Drugs that are causing particular problems include Genentech’s trastuzumab (Herceptin) for breast cancer, which costs about $40 000 a year, and bevacizumab (Avastin), which is licensed in the US for metastatic breast cancer as well as colorectal cancer and non-small cell lung cancer, and which costs about $92 000 a year.
The average wholesale cost for a course of bevacizumab to treat one type of lung cancer is $56 000. If the patient is insured, a 20% copayment comes to $11 200.
Understandably, families of patients want them to receive the best possible palliative treatment. However, doctors and health economists say that the costs, equivalent to the deposit on a house or the cost of a college education, must be measured against the life extension derived from these drugs.
Oncologists, who must carry a stock of many anticancer drugs for intravenous office administration, are responsible for their high costs until Medicare, health insurers, or the patient reimburses them. Insurers often instigate delays or denials of final payment. Some patients cannot afford the high copayments or, in cases of denial of insurance, the total amount.
In a statement last year Genentech announced expansion of its Genentech Access to Care Foundation to help tackle the needs of financially eligible Medicare beneficiaries, who are prescribed erlotinib (Tarceva) approved for particular cases of lung and pancreatic cancer. The drug is marketed in the US by Genentech and OSI Pharmaceuticals, and elsewhere by Roche.
Deborah Schrage and Morgan Hanger from the department of epidemiology and biostatistics, Memorial Sloan-Kettering Cancer Center, New York, last year published a survey of a random sample of members of the American Society of Clinical Oncology, which looked at how oncologists communicate with patients about coping with the costs of chemotherapy (Journal of Clinical Oncology 2007:25;203-7). They got a response rate of 32% (167 replies out of 530).
Most oncologists reported knowledge of their patients’ financial status—15% all of the time, 39% most of the time, 33% some of the time, and 13% rarely or none of the time.
There was substantial variation in oncologists’ attitudes toward discussing the costs of chemotherapy with patients—42% did so always or most of the time, 32% did sometimes, and 26% did rarely or never. Most oncologists (80%) thought that it was important to be explicit about the impact of treatment choices on patients’ finances.
However, 20% maintained that costs played no role in clinical encounters, and 31% reported a high degree of discomfort in discussing costs with patients. Referral to support staff for these discussions was common. Only a few oncologists (16%) acknowledged omitting treatment options on the basis of their perceptions of patients’ ability to afford treatment.
Arthur Caplan, bioethics professor at the University of Pennsylvania, said that the cost of drugs was “one of the toughest issues in oncology,” especially when the price of one drug can mean emptying out “family assets for the possibility of a few more months of life” (Wall Street Journal, 8 Jul, p A18).
Cite this as: BMJ 2008;337:a778