In Reply

Abstract

Dr. Gilligan responds.

I appreciated Dr. Graham's and Dr. O'Reilly's response to my commentary. They raise the important issues of cost unawareness and cost insensitivity in the decision making of oncologists. One wonders whether or not the obscene prices charged for many new anticancer drugs are largely a result of the fact that a substantial number of purchasers do not bear the cost themselves and therefore have no incentive to demand value for their dollar.

Drs. Graham and O'Reilly also raise the important issue of unnecessary waste of these drugs, although dispensing weekly instead of monthly quantities to patients would represent a significant burden of inconvenience for many patients. The issue of taking oral cancer agents with fatty food instead of on an empty stomach is more complex. Although it seems logical that one could save money by using smaller doses—and under many circumstances this is clearly true—cancer drugs are not priced based on the cost of manufacturing them but rather on the principle of whatever the market will bear. The pricing model is based more on what the drug should cost per patient rather than per pill. If it were to be established that some of these drugs could be given safely and effectively at a lower dose when accompanied by food and the standard prescription thus changed to the new lower dose, one might expect the price of the drug to go up to recapture the profit that was originally desired. The most scandalous example of that is seen with alemtuzumab. Marketed as Campath for the treatment of certain hematological malignancies, it has now been pulled off the market to be sold instead at a much higher price as Lemtrada. Why? The dose for leukemia was about $60,000 per year, but when used for multiple sclerosis, a much smaller dose is required, costing only about $6,000 per year. Under the new higher pricing, a year of alemtuzumab for multiple sclerosis is estimated to be $55,000 annually [1]. When the dose goes down, the price goes up to protect profits.

In the end, the only thing likely to result in lower drug costs across the board is for the purchaser to have leverage to negotiate a lower price. Nonetheless, the ability to use a lower dose could increase access to drugs like lapatinib and abiraterone in many regions; studies to determine whether or not a low dose with food is as safe and efficacious as the higher dose on an empty stomach are needed.

Disclosures

The author has indicated no financial relationships.