I'm going to go off on a bit of a rant here on a subject I have not broached on this blog but encounter nearly every day in my practice: the rapidly escalating costs of medical care, cancer care in particular.
At this year's annual scientific meeting for the American Society of Clinical Oncology (ASCO), investigators reported the findings of a trial conducted in lung cancer patients with incurable disease. Here's the snappy title of their report: Randomized phase II/III Trial of paclitaxel (P) plus carboplatin (C) with or without bevacizumab (NSC # 704865) in patients with advanced non-squamous non-small cell lung cancer (NSCLC): An Eastern Cooperative Oncology Group (ECOG) Trial - E4599. The investigators compared the outcomes of treating patients with combination chemotherapy using paclitaxel and carboplatin to those of patients also receiving bevacizumab. The earth-shattering conclusion of the study: "The addition of B to PC in pts with NSCLC (non-squamous) provides a statistically & clinically significant survival advantage with tolerable toxicity. PCB [an unfortunate acronym] is ECOG's new treatment standard in this patient population."
How much advantage did treating with bevacizumab confer? On average, patients went an additional 8 weeks without their disease progressing, and survived 10 weeks longer than those receiving chemotherapy alone. Well, I suppose that's progress.
In an editorial regarding the costs of bevacizumab therapy appearing in the American Journal of Health System Pharmacists by Dr Jill Kolesar, the author notes that adding bevacizumab to chemotherapy increases the risk of vascular complications by a small amount. Perhaps more significantly, bevacizumab costs USD$50,000 for a typical course of treatment.
Does it make sense for a cash-strapped health care system to dispense such an expensive drug for a survival benefit that is measured in weeks? ECOG, a group of cancer treatment facilities in the Northeastern US, has adopted this drug as its standard of care. In the US, once the drug has obtained regulatory approval for its use following a demonstration of its relative safety and effectiveness, it can be prescribed with impunity as long as a payer can be found. For the latest innovations on the market these payers are typically private health insurers or individuals themselves .
The situation in Canada is different. The payer is the government agency overseeing cancer care. Before an anti-cancer drug can be given in this system, it must not only satisfy similar federal regulatory requirements as in the US, it must also be added to the provincial drug formualry if its cost is to be covered. This usually follows an evaluation of its efficacy, toxicity, and clinical and fiscal impact. On some occasions, third party payers can be found for patients who are veterans, in law enforcement, covered by Workers' Compensation, or the like. For the most part, there are no private insurers to foot the bill.
This is probably a good thing from a public health perspective. The third party payers who were pressured in the mid-1990's to cover the costs of high-dose chemotherapy and bone marrow transplantation for breast cancer wound up doing more harm than good. Such a treatment approach has been infamously discredited, with one of the main proponents of the approach--Dr Werner Bezwoda--charged with fraud and dismissed ignominiously. By being late adopters of new treatments, Canadians benefit from a longer experience and more accurate picture of the potential pitfalls of the new treatment. In the meantime, patients are sometimes deprived of the benefits of those treatments.
It is a delicate balance. As a physician, I see my role as an advocate for my patient, seeking to optimize their care. If I am constrained by wait times to tests or operations, the availability of appropriate expertise in my region, the availaility of a drug, etc, then at least I have sought to obtain these things for my patient. Should the system fall short of delivering what I seek, I have to accept these limits or petition to alter them by admittedly byzantine channels.
Practicing in this environment makes physicians in Canada more sanguine than their US counterparts. We cannot gleefully embrace the latest and greatest devices and drugs simply because they exist. We must investigate their effectiveness and pitfalls ourselves, or otherwise prove their advantage before they can routinely be adopted.