What is the value of treatment for individual cancer patients?
My last blog on the costs of drugs for the treatment of myeloma raised a number of issues for discussion, none more so than the heartfelt comment by Robert Fowler, who communicated to us his concerns about costs and the impact those costs may have on insurance for his fellow employees. Questions were also raised about the applicability of the “Value Framework” proposed by the American Society of Clinical Oncology (ASCO) to the assessment of myeloma. Can myeloma be evaluated in the same way as, let’s say, pancreatic cancer or other types of cancer? And what about the model proposed by Dr. Peter Bach at Memorial Sloan Kettering Cancer Center (MSKCC)? Is it reasonable to apply such models in a relatively simplistic and broad fashion?
A fundamental question emerged: will these systems end up harming myeloma patients by mandating suboptimal care and eliminating access to needed drugs? The individual patient value must be considered. But how do we do that?
The starting point is illustrated by a very helpful paper published in the journal Current Medical Research & Opinion, which looks at patterns of total costs for newly diagnosed and relapsed patients with myeloma. This analysis includes both out-of-pocket costs for patients, plus costs that insurers and/or Medicare must pay for the drugs, diagnostic and monitoring testing, plus other costs of ongoing care.
A number of important points emerge. The initial cost of treating myeloma is $10,000 to $15,000 per month, which falls steadily in the next 18 months. The average monthly cost is around $7,000 per month for Revlimid®-based regimens and a little higher, around $10,000 per month, for bortezomib-based regimens. The only part of that is the drug costs. The monthly out-of-pocket costs for drugs that patients actually pay tends to be much lower, from $50 to a few hundred dollars. For example, one study showed that 86% of patients paid $50 to $100 per month for Revlimid as a co-pay. This pattern was confirmed and illustrated by a survey taken at the IMF’s Annual Support Group Leader (SGL) Summit in 2014.
The sobering point, however, is that this is only true in the US. Outside of the US, increasingly, the costs are incurred by the local health authority or central government, which often cannot pay, and costs are passed on to the patient. These are costs that are truly unsustainable and impact treatment selection, care, and outcomes.
A second key point for myeloma patients is that it is economically beneficial to stay in remission, despite ongoing costs of maintenance. Relapse boosts the costs back up to the starting level or maybe even higher. On the medical side, Dr. Antonio Palumbo has been making the same case for the value of continuous therapy, which prolongs both the first and second remissions (PFS1 and PFS2), as well as overall survival. Although it is obviously cheaper to be off maintenance, this appears to be a false savings. But, again outside the US, patients frequently cannot afford the costs of ongoing maintenance.
So, in the US model, why are the costs of cancer care unsustainable? Because more people are developing myeloma and other forms of cancer, and because the costs of novel diagnostics and treatments are high. Quite frankly, it is hard to see how the total costs can go down, certainly in the short term. The most crucial problem is that insurers/payers are faced with too many sick people!
As NPR has reported, 5% of patients contribute to 50% of healthcare costs—and these are not myeloma patients nor even cancer drug costs, which make up only about 1% of the total healthcare budget. The bulk of costs is coming from intensive care for critically ill patients, and from chronic diseases linked to the epidemic of obesity, diabetes, and cardiovascular diseases. Autoimmune and neurologic diseases, such as Alzheimer’s, autism, depression, and neuro-psychiatric conditions are also on the rise.
The problem is—as I mentioned in my last blog—too many “ships in distress.” Very hard to insure. The answer: reduce the burden of disease. Keep Americans and people everywhere healthy! Interestingly, within the Medicare/ CMS model, where total costs are paid for, there is a motivation to have prevention strategies.
As many of you know, I am interested in longevity and staying healthy. Today my daughter Annabel gave birth to a healthy new daughter, Nola. As a result, I am very interested in ways to keep Nola, and all children, healthy and happy over the years. With this in mind, I recommend the recent book, “Brain Maker,” by neurologist Dr. David Perlmutter, who approaches disease in a whole new way and has specific recommendations about diet and activity. I am sure that attempting to stay healthy is an important part of staying in remission longer. What applies to the brain definitely applies to the body overall, and especially, as you will read in the book, to the immune system.
So what is the bottom line for myeloma patients with regard to costs? The key first step is to be aware of and advocate for the best diagnostics and treatment. The International Myeloma Working Group (IMWG) is now working on a tool to help patients do just that—a new set of guidelines that will outline recommended treatments in frontline and at relapse in terms that insurers and payers will understand. These guidelines will not be complex formulae, but simply a listing of the top options based on current levels of evidence and data. These will not be pathways based simply on upfront costs, which can result in false savings. Neither will these listings exclude recommendations based simply on costs. Having myeloma is undeniably expensive. Nonetheless, it will be clearly stated if a less expensive and perhaps more broadly accessible regimen has equivalent, or at least very good, outcomes.
The larger goal is to have fewer patients developing myeloma! Wouldn’t that be great? Maybe we can prevent patients from transitioning from MGUS to active myeloma. That is a discussion for another day.
In the meantime, stay tuned as always.
Dr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.