The Emperor of All Maladies

Today’s Managing Health Care Costs Indicator is $3.9 billion

I just finished reading The Emperor of All Maladies, a Biography of Cancer by Dana Farber oncologist Siddhartha Mukherjee.  It’s a great book – Mukherjee brings to life many of the great historical masters who I learned about in medical school.  He portrays Halsted, who developed the most radical of mastectomies, as a morphine and cocaine fiend. He describes a chicken virologist as “roosting quietly” in his laboratory.  He reminds me that Goodman and Gilman were not merely the authors of the Pharmacology book I struggled with in the second year of med school. They worked together to use the ingredient from mustard gas to treat lymphomas – one of the earliest forms of chemotherapy.  

The book hits its heights when Mukherjee describes his interactions with patients through his training, while I found some of the descriptions of (arcane) disease pathways less engaging.  I was also surprised to see no mention of Betsy Lehman, the Boston Globe health columnist who lost her life to a chemotherapy overdose in 1994.  Her death, and the surrounding outcry, helped make Dana Farber what it is – a patient-centered institution wholeheartedly committed to safety.

Emperor of All Maladies is a stirring reminder that health care has gotten dramatically better since I graduated from medical school.  The emergence of biopharmaceuticals which target the genes that regulate cancers means that many patients who would have died quickly now live normal lives.  Here’s an example.   Only a few thousand are diagnosed with Chronic Myelogenous Leukemia (CML) each year, and the disease was usually fatal within a few years.  This was a market so small that a researcher had to beg the drug giant Novartis to synthesize a few grams of a highly promising drug to do human tests.  The drug maker had already given up on the drug. The drug, Gleevec, apppears to keep CML quiescent for an estimated average of 30 years, and current estimates are that there will be a quarter million Americans living with CML in the next decade. Annual sales of Gleevec now are $3.9 billion

Which brings me to costs.

The newer biologic agents are hugely expensive. They’re often much less toxic to patients than conventional chemotherapy, so there are fewer humanistic reasons not to push hard with these medications – which are sometimes used in combination.  There are usually few choices, and there are no meaningful controls on the unit price for these life-saving medications. 

The problem is straightforward.   Avastin, at $100,000 per year, just lost its FDA indication for breast cancer because in most subgroups it did not increase survival.  Herceptin is a miracle drug for many with the Her2 receptor. The cost?  $70,000

The answer isn’t simple at all, and many of the techniques that have helped to control costs of other medications look like they’ll be useless in dealing with the biopharmaceuticals and genetic-targeted medications.
·        There is not going to be a “market” to help control the costs of these medications, because there will be no competition for each medication.  
·        Benefit design changes, like increased coinsurance or deductibles, won’t change demand for these medications – since anyone needing them will always be beyond any reasonable out of pocket maximum. 
·        Health plans might try to avoid coverage by saying that they are experimental -- but it’s hard to withhold a drug when there is nothing else that would offer any hope at all.
·        The Affordable Care Act offers a route to biologic generics – but realistically it will take many years before biogenerics take off, and continued innovation in the biopharmaceutical area is likely to continue to raise the overall costs.

We have an embarrassment of riches in medicine – drugs that bring a normal and comfortable lifespan to those who would have died just a few years ago.  But we increasingly we risk impoverishing the sick –and all of us.