How Much Is Two Months of Life Worth?: Expensive Cancer Drugs
Although only after we face the decision in some personal way (ourselves or a family member), it is very hard to answer the question "How much is two months of life worth?" And yet patients with cancer, those who have failed other cancer drugs, are having to make such decisions, if they can. Other considerations on the same issue are why the pharmaceutical companies must charge astronomical prices for these drugs which only give to most patients only very limited benefit? Also, who should be paying for these drugs? Should they be available to the illegal immigrants who appear in emergency rooms very sick with cancer? To help us think further and answer some of these questions, I found a very worth while blog, In The Pipeline, written by a pharmaceutical researcher, covering this very topic and followed up by a bunch of very cogent visitor commentaries by people who seem to know in ins and outs of pharmaceutical companies and research. Take a look at the posting there and then return and give me your comments. Do you think you can answer the question "How much is two months of life worth?" ..Maurice.
posted by Maurice Bernstein, M.D. @ 3:34:00 AM
11 comments
11 Comments:
If the miracle drug would save my life, that's one thing, but for an extra couple of months, I'd decline for a number of reasons.
1. Why put my family through 2 more months of anticipatory grief when they know the inevitable will happen?
2. In my life time, if I were a cancer patient, I've already given the pharmacy company my fortune and my soul in an attempt to cure me or at the minimum make me comfortable.
3. I think I'd rather have my money go to a monument, much like the Vietnam War Monument, with the inscription, "These people died because of pharmaceutical greed."
My Own Woman, Great! Those reasons are better than many other excuses one could give. ..Maurice.
Can a Dr. not tell a patient they are going to die in a matter of weeks to months?
Anonymous from today, you have touched on an important point in the doctor-patient communication. First, it is NOT the doctor that would initiate a conversation over when a patient might die from a potentially lethal illness, like cancer. Physicians usually should wait until they understand what information the patient wants to be told about their fatal illness. This understanding is accomplished by careful, thoughtful and supportive talk. And the doctor doesn't just start out the talk with "Do you want to know when you are going to die from this illness?" That harsh question is in a way unrealistic since in many cases the doctor cannot answer the question if that question is the one the patient wants to ask. Notwithstanding what you see in medical TV dramas, doctors are not God and doctors don't know. They can give, if the patient desires, often in order to arrange personal family matters, some statistical information from the literature regarding the outlook for the patient's illness but this may not apply to this specific patient. I think the only time a physician can usually tell that death is near is when death is actually only a week or two away but it still depends on many factors. Usually, in the case of end-stage cancer at a week or so a prognosis of death soon is obvious. But when death turns out to be 6 months or more away, no timeline for the patient can be given except for the statistics. At a week or two before death, often the patient is aware that death is near and the physician need not tell the patient anything unless the patient asks. And the emphasis should not be on the physician talking about dying but the emphasis of the physician's attention should be on listening to the patient and talking to the patient about the comfort care that the physician is monitoring and administering over the upcoming days or longer. Anonymous, I hope this answers your question. ..Maurice.
The difficulty in deciding what to do is some patients may not be helped at all by an expensive treatment and others might live much longer than expected.
I have had two different types of cancer, Hodgkin's Lymphoma and thyroid cancer. Even with fairly standard treatments, cancer is a very expensive disease to treat. It would be a real tough call if I needed a medication that was super expensive.
I would never want to take a drug that would simply prolong a steady decline towards death. The medicine would have to represent an improvement is quality of life before I would even consider it.
MJ KC, your response is also very rational and appreciated. The "tough call" for all cancer patients faced with decisions about therapy, particularly when previous therapy has not met expectations, is what will be the outcome "for me" with the new and perhaps even more expensive medication. The problem is that nobody including the physician or the pharmaceutical company can know with absolute cetainty when the therapy is administered to the specific patient whether the outcome will be similar to a number of other patients with the same disease. This is where the accumulated statistics fail and where, even if the outcome turns out to be poor, until the drug is tried there can remain hope. This is why desperate cancer patients request as yet FDA unapproved medications or meds that have been approved but are astronomically expensive. If all patients pathophysiology was exactly the same and the therapeutic effect of a drug was identical on each patient, it would make living or dying with a disease like cancer, though unwanted, much more simple and uncomplicated, wouldn't it? ..Maurice.
A treatment would have to represent a fairly significant likelihood that my life would be extended by a year or more before I would even consider a really expensive treatment. If the median extension is only 2 months, the answer would be no without any difficulty in deciding this.
Everything related to cancer treatments is about typical outcomes versus the cost. The problem is that there can be extreme statistical variations in how other people have already responded to a given treatment. No doctor can tell an individual with any degree of certainty just what their specific outcome will be.
It is important that people understand this so they don't blame their doctor if they end up on the short end of the stats.
"It is important that people understand this so they don't blame their doctor if they end up on the short end of the stats."
Yes, unless the doctor made it sound to the patient that he or she, by being the patient's physician and aware of all the facts in the patient's specific situation, knows something more to make a prognosis beyond the statistics. Hopefully most doctors won't express to their patients this appearance of a "know it all".
But some might---a kind of "I'm in charge" attitude to try to make a solid connection with the patient. ..Maurice.
Some cancers may grow so slowly that the person eventually dies from a cause other than cancer and some cancers develop and grow rapidly and cause death in just few months.
The Ethical, Moral, and Financial Implications of Biopharmaceuticals.
Recently, you may have heard or read in mass media sources about the issue of pharmacy benefit managers who have clients that are prescribed biologic medications. These patients are required to pay a great deal of money for such meds due to the placement of these types of medications on their PBMs. This is due to the status on the PBM of biopharmaceutical medications, which is known as Tier 4 status, which requires patients to pay higher co-pays for these meds. Tier 4, which also includes lifestyle meds, is determined by the PBM based on variables such as rebates and discounts from the manufacturer, which are intended to be passed on to the PBM clients, and is similiar as to PBMs requiring prior approval before reimbursement. However, in some cases, the PBMs fail to do this, and have been penalized for their self interest above patient interest as required when this activity is discovered.
Regardless, because of the tier 4 status of biopharmaceuticals, very sick patients have to pay a great deal of money for these meds. PBMs, by the way, are pharmacy benefit managers created for the pharmaceutical needs of employees normally and is a benefit along with their insurance through their employer. Typically, PBMs are an element of managed health care plans, yet determined by employers as far as what is paid through negotiations with PBMs, typically.
First of all, biopharmaceutical meds are specialty meds created differently than other typical meds, and therefore are have a unique molecular complexity that are designed for serious illnesses such as anemia or multiple sclerosis. Because of their uniqueness and exclusivity, they are very expensive- costing thousands a month for the payers. In addition, generics are not authorized to be produced as of yet for these types of meds. The cost of these biological meds is due more to the complex process of their creation, as the material costs are typically less expensive than traditional molecular medications, it is believed.
Biologic medications began to be used primarily in the 1980s and now presently make over 60 billion a year, with about 20 percent growth in this market annually. With anemia patients, oncology and dialysis clinics are targets for such meds in this category, as anemia is associated with their treatment and conditions for such diseases.
Yet, some claim that biopharmaceutical meds benefit patients to only a certain degree, as they do in fact extend the life of such patients, such as those on chemotherapy or dialysis, but by only a few months. So the high cost of these meds is questionable and has been analyzed by others, yet no substitutes exist for biopharmaceuticals, which is probably why the producers of these drugs can charge so much for these products. Efficacy of these biologic meds have also been questioned as well in other treatment aspects aside from life extension.
Then there is the issue of fraud with kickbacks and overuse of some of the biopharmaceutical meds used to treat anemia in dialysis clinics in particular. On a few occasions, doctors and clinics have been penalized for overusing the meds and for kickbacks in the form of discounts of the manufacturers. Ironically, the dialysis process was never patented, yet the many centers that exist have proven to be very profitable, more for some than others. An example is the situations where dialysis doctors, called nephrologists, have been accused of over-dosing patients with biologic meds to increase their income through their discount arrangement through the manufacturer of such meds, such as those biologics for anemia, and this arrangement is being investigated by regulators and encouraged by the representatives of such meds.
Presently, there are many that approach the FDA to aggressively insist that generic biologics be allowed into the market for the benefit of these critically ill patients, and this would be of great benefit for such patients, and this can be done, as far as the generic creation of these types of medications. And thier efforts have been somewhat successful, as generic equivalents of biopharmaceuticals, called biosimilars, could be manufactured and available within the next few years. However, this situation of delays illustrates one of many flaws in the U.S. Health Care System- when the sickest have to complicate their illnesses by possible financial stress, such as the case with biologic meds. Relief is needed, and should be demanded by the public. After all, why be so sick, and then be financially burdened? One solution or suggestion is to either lower the cost of these types of drugs, or allow generic forms to enter the market faster than what the situation is presently.
“A little learning is a dangerous thing.” ---- Alexander Pope
Dan Abshear
Author's note: What has been written has been based upon information and belief.
Dan Abshear
The truth of the matter is, all cancer drugs are expensive
no matter what the compound. Consider Taxol,which is
used for ovarian cancer. It is extracted from the bark
of the pacific yew tree. Now these trees must be between
150-200 years old. Big pharma initially contracted
the weyerhauser company to cut down the trees and
trim the bark.
At one point an environmental group tried to stop the
harvesting of these old trees. One can only imagine the
final costs.
PT
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