Health

Max Nisen is a Bloomberg Gadfly columnist covering biotech, pharma and health care. He previously wrote about management and corporate strategy for Quartz and Business Insider.

Cancer drugs have mostly been immune to the pricing pressure affecting many drugmakers. That's likely to change, even for new and potentially curative drugs. 

Bristol-Myers Squibb CEO Giovanni Caforio recently told Bloomberg News he doesn't expect to see intense pressure to cut cancer-drug prices. He had better hope not: Bristol-Myers is a leader in immuno-oncology (IO) drugs, which boost the immune system to fight cancer. The drugs can be highly effective, but at a mind-blowing cost. Bristol-Myers sells a combination of two, Opdivo and Yervoy, that costs $256,000 per patient in the U.S.    

Cancer drugs do face far less price pressure than medicines that target bigger populations. But the prices of these drugs are growing at an unsustainable clip. The IO market is getting crowded and competitive. Bristol-Myers is already competing for patients with Merck, which has an IO drug similar to Opdivo. Roche just had its own IO drug approved by the FDA, and the market will eventually balloon into a five-way scrap involving Pfizer and AstraZeneca.

Meanwhile, a wave of pricey combos will test the market's limits. And political pressure on drug pricing generally is growing in the U.S., which shoulders a disproportionate burden of cancer-drug costs. Something's got to give.

Rising Tide
A new generation of immune boosting cancer drugs is going to see spending skyrocket. Analyst consensus projected sales.
Source: Bloomberg

According to IMS Health, a health-care data and technology services company, worldwide spending on cancer drugs reached $107 billion in 2015, an 11.5 percent increase from 2014. Global spending may reach $178 billion by 2020. That growth will be heavily concentrated in the U.S., which accounts for 46 percent of the market for cancer drugs. U.S. cancer-drug spending is up 72 percent in the past five years, driven by a wave of new medicines.

Even more are on the way, and they're only going to get more expensive.

global-oncology-costs

The U.S. dominates cancer-drug spending mainly because its drug prices are shockingly higher than those in the rest of the world. A large study of cancer-drug prices released earlier this month found the median monthly cost for patent-protected cancer drugs in the U.S. is more than double the cost in any of five comparison countries. 

new

Additionally, U.S. government programs such as Medicare are obligated to pay for essentially all cancer medicines, regardless of their effectiveness or cost. Similar programs in other countries do a cost-benefit analysis before they agree to pay. If a drug's ability to add quality years to a patient's life doesn't justify its price, then they don't pay for it. 

All Aboard
U.S. government programs like Medicare reimburse every cancer medicine that's been approved in the last two years. Other countries? Not so much.
Source: IMS

Private insurers can't or don't push as aggressively for price discounts on cancer drugs as they do on many other expensive medicines. According to IMS, discounts and rebates managed to shave nearly 4 percent from overall drug-price growth last year in the U.S. In cancer, it was just 1.6 percent. As costs continue to rise, though, cancer drugs will likely finally see more pricing pressure. 

The incredibly high list price of Bristol-Myers' IO-drug combo is actually a discount on what you'd pay to buy both drugs separately. The combo is being tested in a wide variety of cancers, and this approach is becoming more common generally. When combinations from multiple companies hit the market, pricing will get complicated. 

combo-price

The next few years will bring a tsunami of data on IO drugs and combos. There are more than 200 ongoing trials involving Merck's Opdivo competitor Keytruda alone, including many combinations with other drugs. The other four companies furthest along in the IO race are running hundreds more trials. Not all of them will succeed. But enough will that Opdivo-Yervoy's $256,000 price tag won't be an outlier for long. 

And IO drugs aren't the only ones being tried in combos. A combination of Johnson & Johnson's Darzalex and Celgene's Revlimid looks highly effective in treating a blood cancer. The drugs could cost in excess of $200,000 together, and they'll likely prompt more combo studies outside of IO.

The public sector can't ignore rising drug costs forever, and there are early rumblings of a pushback. Members of Congress recently targeted Medivation's prostate-cancer drug Xtandi in an attempt to lower its price, and a broad Medicare effort to reduce drug costs may hit some cancer drugs if it is implemented as initially designed. 

The private sector, meanwhile, likely won't ignore the opportunities granted by greater competition. Companies that are later to market with new drugs will likely try to compete on price, eating into the industry's profit margins. And some of the aggressive price negotiation tactics pharmacy benefit managers (PBM) have used in other drug classes will likely make their way to cancer. Express Scripts, one of the two largest PBMs, has pledged to be more aggressive about cutting costs for cancer treatments. 

The ensuing price wars may not reach the exact fever pitch seen in Hepatitis C, where PBMs have extracted discounts of 50 percent or more on expensive combination therapies. But they are coming one way or another. 

The first to feel the pressure will likely be drugs that charge a great deal to add only a month or two, or less, to patients' lives. For example, the Roche drug Tarceva adds five months, on average, to the lives of lung-cancer patients, and sometimes years. But it gives just days or weeks, on average, to pancreatic-cancer patients. Yet both sets of patients pay the same price for the drug. 

Even effectiveness does not grant immunity forever; charging $200,000-plus per patient is not a sustainable norm. Anyone expecting the status quo to extend indefinitely is in for a nasty surprise. 

-- Graphics by Rani Molla 

This column does not necessarily reflect the opinion of Bloomberg LP and its owners.

To contact the author of this story:
Max Nisen in New York at mnisen@bloomberg.net

To contact the editor responsible for this story:
Mark Gongloff at mgongloff1@bloomberg.net