Commentary: Cancer Superdrugs, Costly Side Effects

New therapies are extending lives, but the prices could weigh down the nation

A revolution is coming in cancer treatment, and Charles G. Gibson is on the front lines. By rights, the 51-year-old Houston truck driver shouldn't be alive today. He was diagnosed with advanced lung cancer in July, 2001; only a fraction of such patients live more than a year. After undergoing a year of debilitating chemotherapy, Gibson was told to prepare for the end. Instead, he enrolled in an unusual clinical trial.

It proved a very smart move. Dr. Roy S. Herbst, a lung cancer specialist at M.D. Anderson Cancer Center in Houston, put Gibson on a combination of Avastin, a new colon cancer drug, and Tarceva, an experimental lung cancer treatment. The two drugs, both from Genentech Inc. (DNA ), are part of a new generation of targeted therapies designed to block a tumor's growth and tame cancer into a chronic yet manageable illness. After just a few months Gibson's tumors had shrunk by an almost unheard-of 90%. "I consider myself an optimist," says Gibson. "But I found that hard to believe." The plan now is to stay on the two drugs for as long as the disease is held at bay. While not a cure, that's a far sight better than the alternative.

$20,000-a-Year Drugs

Freak recovery? Not at all, say oncologists who believe Gibson's experience could become commonplace in a few years. But one aspect of his treatment could remain a major obstacle: the enormous price. Standard chemotherapy costs a few hundred dollars a month, but Avastin, a drug taken intravenously, lists for $4,400 per month. Tarceva, a pill likely to be approved by the Food & Drug Administration later this year, is expected to cost close to $2,000 a month.

Those sorts of prices, typical for the growing array of therapies that target specific cellular mutations, threaten to put an enormous burden on an already strained health-care system. An estimated 174,000 people will be diagnosed with lung cancer in the U.S. this year. If even a small fraction of those patients receive just one of these targeted therapies, the cost would be huge. And as the acceptance and usage of such drugs spreads, those costs could grow exponentially, blowing the nation's health-care bill into the stratosphere. Already, national cancer care totals $64 billion a year in direct costs and $125 billion more in lost productivity, according to the National Cancer Institute. And because cancer is the most prevalent in those over 65, those costs are sure to rise as the population ages. "How can we afford to pile $20,000-a-year drugs on top of $20,000-a-year drugs?" asks Dr. Michael A. Friedman, CEO of City of Hope National Medical Center in Los Angeles. "This could completely exhaust the national health-care budget."

With all the rapid advances, the U.S. will soon face hard choices about how much it wants to spend on cancer treatments -- and who will get them. Yet the looming cost conundrum received scant attention at the country's premier cancer meeting on June 5-8. Though the 27,000 attendees at the American Society of Clinical Oncology gathering in New Orleans were presented with an array of breakthrough results, there were no sessions devoted to costs.

No doubt, there's plenty to get excited about. Most satisfying for the oncologists: progress fighting the four most intractable cancer killers -- lung, colon, breast, and prostate. Study after study demonstrated that both the new generation of targeted therapies and better uses of older chemotherapy drugs were able to extend the median survival for patients with late-stage cancer, which until now has usually been a death sentence. "The very notion that you can take a couple of pills and shrink a solid tumor like colon or lung cancer is a mind-boggling event," says Dr. Robert J. Mayer, director of gastrointestinal oncology at Dana-Farber Cancer Institute in Boston. "It's a brave, wonderful new world."

Yet something has to give. New drugs have enabled doctors to almost double the median length of survival for advanced colon cancer over the past five years, to 22 months. During that time, notes Dr. Leonard Saltz of Memorial Sloan-Kettering Cancer Center in New York, the wholesale cost of the drugs used to treat a single colon cancer patient has shot up from $500 in 1999 to $250,000 today. Insurers have been willing to pay so far because drugs are still cheaper than surgery. And until now, patients haven't lived long enough to become a huge cost burden. But as survival rates creep up, price will become a much bigger issue. "There is not enough money in the till to treat everyone," Saltz warns.

Drug companies insist they must price drugs high to recoup development costs, which run as much as $800 million per drug. Yet as doctors figure out new uses, prices should come down. Drugs like Avastin and ImClone Systems Inc.'s (IMCL ) Erbitux, though approved for colon cancer, take aim at mutations found in a wide range of tumors. Erbitux, for example, which costs $12,000 per month, got a lot of attention at the ASCO meeting for a clinical trial which found that the drug can extend the median survival for patients with head and neck cancer to 54 months from 28. ImClone CEO Daniel S. Lynch says that as a drug is approved for more types of cancer "we'll have to make an assessment of the pricing."

Better diagnostic tests would help. Most therapies have notoriously low response rates: AstraZeneca PLC's (AZN ) Iressa, which goes for $1,700 a month, works on just 10% of lung cancer patients. Researchers are working on methods to correlate specific mutations with a drug's effectiveness so they can avoid giving the treatment to that other 90%. But such tests are difficult to develop. Moreover, patients want to try any drug they think might help.

Oncologists, pharmaceutical companies, and the government will have to focus on the best way to lower prices for these drugs. More work on diagnostics and a streamlined approval process would be a good place to start. Meanwhile, society must face a difficult dilemma: Is treatment, no matter how low the chance of success, always worth the price? And if not, how will we decide who gets a drug and who will be denied?

By Catherine Arnst

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