The Cost of Cancer Care

[Parts Unknown]

Saw this article today by Dr. John Marshall, a practicing oncologist. I thought it might stir some discussion.

Excerpt from Fighting a smarter war on cancer:

In the extensive debate over health-care reform, we have heard little discussion about the enormous cost of cancer care. (Some of the only voices to broach the subject are those fearing "death panels.") But at this moment, when a significant shift in the health system in this country is possible, we must ask some difficult questions: Does it make sense to support cancer care at the current levels in the United States? Who should determine the value of care?

At the moment, there is a giant disconnect between patients, the cost of care and the clinical benefit of the treatment -- a disconnect that has caused us to lose perspective. When it comes to cancer care, we're not getting what we pay for.

Cancer medicine is often regarded as an area of significant progress and clinical research, so we should be able to tell without much difficulty what kinds of treatment are valuable and what kinds aren't. But given that 80 percent of my patients will die of their cancer, it's clear that we have not found an "optimum" therapy.

In 1971, President Richard Nixon declared war on cancer, with the charge to "cure" the disease. Since then, billions of dollars have been spent on research, yet we have made only minor real progress. The most common approach to treatment involves exposing large populations of patients to highly toxic poisons in the hopes that the treatment will kill the cancer cells and not the patient.

This strategy has succeeded with several types of less-common cancers, curing some patients with leukemia, lymphoma, testicular cancer and most childhood cancers. But it has not worked for more common forms of the disease, including breast, prostate, lung, colon, pancreas, stomach and ovarian cancers. These cancers represent an enormous public health problem, consuming the majority of our cancer-specific health-care costs and research dollars.

In many ways, we have quit trying to win the war on these diseases. Few cancer clinical trials are designed to "cure" patients. They are commonly aimed at detecting small differences between the treatments being compared: an extension of average survival from 5 months to 6 months, for example. These trials typically cost millions of dollars (often including taxpayer support), take years to complete and can involve thousands of patients. It is this kind of care that many Americans are afraid they will lose access to as a result of health-care reform.

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[Charles_Carmichael]

Thanks for the interesting link. I'm currently in a cancer cell bio course and I love it. But with every lecture, it always seemed like research was progressing at an exponential rate. I guess that even though we understand some of the mechanisms behind tumor development much better than we did a few decades ago, it's just not translating into clinical application.

One problem seems to be that it's hard to develop chemotherapeutic agents that are specific for cancerous cells but leave the normal cells alone. For example, inhibiting the kinase domains of enzymes implicated in cancer not only affects those particular proteins, but also other proteins (that might be critical in normal cell physiology) that share similar kinase domains.

Another problem seems to be with some of the more radical immunotherapies such as ACT in that it works sometimes, but not always. At other times, it even works to help the tumor rather than boosting the immune response against the tumor.

My research doesn't have anything to do with cancer, but how can we improve the specificity of drugs, the efficacy of immunotherapies, etc? My understanding is that it's a slow process with a lot of trial-and-error rather than something that can be seen occuring in vitro or in a mouse model and automatically working in humans. So I can understand that there hasn't been a significant improvement in clinical treatment of cancer over the past decade or two.

Also, what about radiation therapy? It's a field I'm very interested in and am considering doing a year of research in this field before med school. My understanding has been that this is a very research-intensive field and the future looks bright. Can anyone comment on how well this field is progressing in terms of clincal application resulting from research?

Dr. Marshall mentions that the future of cancer treatment is personalized medicine. I completely agree with this. However, what will the cost of personalized medicine be? From what I've gathered from various immunology/tumor immunology courses, etc, personalized medicine is pretty expensive. And with the number of people with cancer increasing, how expensive will this turn out to be? And what level of personalization will be deemed the standard?

Edit: Also, it seems like the NIH is making a big push towards translational research. They're putting a lot more money into it than they have before. I feel like this would help quicken the translation of basic science knowledge into clinical application and that progress would occur at a faster rate. However, since I've not been involved in a translational lab, maybe someone who's been in such a position can comment on how effective translational research has been so far in comparison to spending a decade or more in basic science research before moving on to clinical trials.

 

[7starmantis]

The future of cancer care will rely on personalized medicine.

So how are we moving towards more personalized care in this country? Seriously.

 

[WNT Signaling]

So how are we moving towards more personalized care in this country? Seriously.

We currently have mounting data using SNP analysis to determine which drugs will and won't be effective for individuals

In terms of cancer research, there is considerbale amounts of research that is moving towards the clinic that uses microarrays and high throughput sequencing to determine which genes and pathways have been perturbed in someone's cancer. Therefore, if we know what genes and pathways have been perturbed, then we know which cancer drugs will be most effective against their unique cancer, unless their cancer is polyclonal :/

The big problem is that we do not have the technology to do high throughput sequencing in a timely and cost effective way, but once we do, we will truly enter an age of personalized medicine

 

[7starmantis]

How do insurance companies address these types of advances? Are they normally paid for without question, not paid for, some do some dont, etc ?

 

[boaz]

"At the moment, there is a giant disconnect between patients, the cost of care and the clinical benefit of the treatment..."

If I was required to sum up the problem in one sentence that's what I'd say.

 

[CoolWhipp]

We currently have mounting data using SNP analysis to determine which drugs will and won't be effective for individuals

In terms of cancer research, there is considerbale amounts of research that is moving towards the clinic that uses microarrays and high throughput sequencing to determine which genes and pathways have been perturbed in someone's cancer. Therefore, if we know what genes and pathways have been perturbed, then we know which cancer drugs will be most effective against their unique cancer, unless their cancer is polyclonal :/

The big problem is that we do not have the technology to do high throughput sequencing in a timely and cost effective way, but once we do, we will truly enter an age of personalized medicine

This is exactly why I believe in the next 10-15 years, people will have their genome sequenced. People can't get away from genome sequencing. There are way too many health benefits to the individual that knows their genetics to simply ignore.

 

[Drrrrrr. Celty]

This is exactly why I believe in the next 10-15 years, people will have their genome sequenced. People can't get away from genome sequencing. There are way too many health benefits to the individual that knows their genetics to simply ignore.

genetic sequencing ah.. that'll lead to gene molding and modification and boom..
a generation of whinny young immortals.. hmm...

 

[AirmanCatalyst]

This is exactly why I believe in the next 10-15 years, people will have their genome sequenced. People can't get away from genome sequencing. There are way too many health benefits to the individual that knows their genetics to simply ignore.

I'm sure that there will be a great deal of debate on the issue, but I hardly doubt that the ball will get moving quickly enough for it to actually to be in place in that short of a time period, if ever. Way too many ways for that information to be abused for people to sign off on it even if it is affordable for the everyday 30k salary individual. They are saying its 4400 + labor, equipment, and lab space costs as well as data post-processing costs. Who's going to be willing to pay 1/6 of their salary on something which may not be useful and has the posibility of being detrimental to their safety, privacy, and who knows what else.

 

[Parts Unknown]

I'm sure that there will be a great deal of debate on the issue, but I hardly doubt that the ball will get moving quickly enough for it to actually to be in place in that short of a time period, if ever. Way too many ways for that information to be abused for people to sign off on it even if it is affordable for the everyday 30k salary individual. They are saying its 4400 + labor, equipment, and lab space costs as well as data post-processing costs. Who's going to be willing to pay 1/6 of their salary on something which may not be useful and has the posibility of being detrimental to their safety, privacy, and who knows what else.

The $1,000 genome project has been going on for over 6 years, and GE might be getting close (with IBM and others in the race). I have no doubt the cost will eventually plummet to the low hundreds. Not bad for a one time investment that will presumably help guide medical care for a lifetime.

The ethical, legal, and social issues will have to be hashed out over the years, but so it is with historic advances in medical science. At least we have the Genetic Information Nondiscrimination Act, which was signed into law by President Bush last year.

 

[ijn]

Why shouldn't you be able to get cheaper insurance because you have better genes and environmental influences? The insurance industry is not a public service. It is a vessel for profit.

 

[Narmerguy]

Why shouldn't you be able to get cheaper insurance because you have better genes and environmental influences? The insurance industry is not a public service. It is a vessel for profit.

But will it stay that way?

 

[Parts Unknown]

Why shouldn't you be able to get cheaper insurance because you have better genes and environmental influences?

We tend to divide our symapthies based on controllable factors versus non-controllable factors. Your genes, gender, age, skin color, the socioeconomic status of your parents - these are things you did not ask for when you spilled forth into the world. Hence, you should theoretically shoulder no blame for them.

If, on the other hand, you choose to smoke, drink, use intravenous drugs, and womanize, don't expect so much compassion for your lung cancer, cirrhosis, hepatitis, and syphilis.

The insurance industry is not a public service. It is a vessel for profit.

One of the arguments for making all private health insurers non-profit entities.

 

[7starmantis]

Why shouldn't you be able to get cheaper insurance because you have better genes and environmental influences? The insurance industry is not a public service. It is a vessel for profit.

The same reason you shouldn't be able to make lots of money without paying 50% taxes even if you do have better judgement, work ethic, business skills, and intelligence.

 

[LizzyM]

The vast majority of adults with cancer do not participate in clinical trials of experimental drugs or other treatments for their disease.

The vast majority of children with cancer do participate in clinical trials.


Where has more progress been made in the last 30 years, with kids or with adults?

Clinical trials provide the experimental drug at no charge. The patient (and the patient's insurance coverage if applicable) pay for the usual care that usually goes along with the experimental treatment (e.g. cancer studies usually compare usual care to usual care plus something more.) If it is routine to get a CT scan every 6 mos then the subject will get a CT scan every 6 mos and insurance will be billed, no different than not being in a trial. If the protocol for the study specifies CT every 3 months then the study will generally pick up the cost of the additional CT scans.).

Most cancer treatments have been disappointing and we will get our biggest bang for the buck in detecting cancer early, before it spreads. More research should be focused on improved methods of early detection and ways of identifying those at high risk of developing cancer so that they can undergo more frequent surveillence.

 

[ijn]

The same reason you shouldn't be able to make lots of money without paying 50% taxes even if you do have better judgement, work ethic, business skills, and intelligence.

You are making a false analogy. The insurance industry is not part of the government. It does not serve a public interest. It exists to make money. If having a set of alleles versus another set of alleles results in drastically lower rates of some common and/or expensive disorder, then it makes sense that that person's insurance policy should cost less per month.

 

[7starmantis]

Most cancer treatments have been disappointing and we will get our biggest bang for the buck in detecting cancer early, before it spreads. More research should be focused on improved methods of early detection and ways of identifying those at high risk of developing cancer so that they can undergo more frequent surveillence.

I agree completely. While I'm all for clinical trials, we should focus allot of our resources on early detection (not that it isn't already) I hate caveats.

You are making a false analogy. The insurance industry is not part of the government. It does not serve a public interest. It exists to make money. If having a set of alleles versus another set of alleles results in drastically lower rates of some common and/or expensive disorder, then it makes sense that that person's insurance policy should cost less per month.

Sorry, again should have had the [sarcasm][/sarcasm] tags again. It was more about an ideology than anything else.

 

[Longshanks]

genetic sequencing ah.. that'll lead to gene molding and modification and boom..
a generation of whinny young immortals.. hmm...

slippery slope and also if you know anything about genetics, gene therapy doesn't work. lay off the sci-fi and glenn beck and pick up a science book.

 

[Parts Unknown]

If having a set of alleles versus another set of alleles results in drastically lower rates of some common and/or expensive disorder, then it makes sense that that person's insurance policy should cost less per month.

If you consider the entire equation it does make sense to ignore genetic predisposition for purposes of health insurance. There are several arguments one could make, but IMHO the most important one (by far) is that to do otherwise would severely disincentivize getting sequenced. Thus, the entire goal of personalized medicine would be hamstrung in the interest of risk adjustment.

You mentioned profit, but if an insurer raises some premiums and lowers others, it is still operating a zero sum game. Better to ignore genetic predisposition (which can usually only give estimates of future risk) and instead give everyone a more predictable, level premium. Given that few people really knows what is lurking in their genes, or their spouse's, or their children's, I believe most people would find this preferable.

 

[Longshanks]

You are making a false analogy. The insurance industry is not part of the government. It does not serve a public interest. It exists to make money. If having a set of alleles versus another set of alleles results in drastically lower rates of some common and/or expensive disorder, then it makes sense that that person's insurance policy should cost less per month.

As already pointed it, its discriminatory against factors of which you had no control of. We're a society founded upon liberty and equal opportunity, discrimination based upon what you were born into does not adhere to those fundamental American principles. Insurance companies can set policies in place based upon your controllable behavior and the environmental factors you bring upon yourself, however.

Most cancer treatments have been disappointing and we will get our biggest bang for the buck in detecting cancer early, before it spreads. More research should be focused on improved methods of early detection and ways of identifying those at high risk of developing cancer so that they can undergo more frequent surveillence.

This is absolutely the direction oncology needs to go. Preventing or limiting the factors promoting cancer, and developing technology for earlier detection will go a much further way. Most grade I's can be treated with relative ease, but depending on the tumor site some cancers aren't detected until grade III and the clinical picture is completely different.

There is also the argument that if we can't cure cancer at the moment, why not develop treatments to limit it to a chronic condition which you'll die with but not from, much as the direction of HIV/AIDs treatment has gone and imantinib for CML for example.

I still have faith in our ability though to find novel therapuetic targets, and to improve treatment regimens through combination therapy targeting multiple pathways so to develop curative treatment. Its also important to promote a comprehensive approach and interdisciplinary understanding, not just focusing on tumor genetics, or tumor immunology, or tumor structure for example. We may need to change our approach of finding targets that 'cure all cancer' (the old NIH method) and look to improve treatments for specific cancers, which has been the direction some institutions are moving towards. Yet, even with that goal, early detection is a necessity since due to the math of genetic mutation and tumor biology, some tumor cells may already be clinically resistant by the point of clinical detection with current technology and protocols.

 

[greatnt249]

slippery slope and also if you know anything about genetics, gene therapy doesn't work. lay off the sci-fi and glenn beck and pick up a science book.

I suggest you follow your own advice and "read a book" before attacking others; while gene therapy isn't foolproof, it has its benefits.

http://www.sciencedaily.com/releases/2009/11/091105143706.htm

 

[ijn]

If you consider the entire equation it does make sense to ignore genetic predisposition for purposes of health insurance. There are several arguments one could make, but IMHO the most important one (by far) is that to do otherwise would severely disincentivize getting sequenced. Thus, the entire goal of personalized medicine would be hamstrung in the interest of risk adjustment.

You mentioned profit, but if an insurer raises some premiums and lowers others, it is still operating a zero sum game. Better to ignore genetic predisposition (which can usually only give estimates of future risk) and instead give everyone a more predictable, level premium. Given that few people really knows what is lurking in their genes, or their spouse's, or their children's, I believe most people would find this preferable.

You can't control your age and it's one of the largest factors in the cost of insurance because it makes sound actuarial sense. Your genetics should be no different.

Moreover, simply because you were sequenced does not mean that this information would be revealed to your insurance provider. Obviously this information is sensitive would only arrive at their desk upon your explicit authorization. Perzonalized medicine would not be hamstrung unless there were a ridiculous policy whereby sequencing became public domain knowledge.

 

[Drrrrrr. Celty]

slippery slope and also if you know anything about genetics, gene therapy doesn't work. lay off the sci-fi and glenn beck and pick up a science book.

what is usually science fiction
usually becomes reality

we've figured out that telemerase is the key to genetic stability and the sametime
genetic instability; cancer

its only a while until we modify telemerase and boom..
aging is gone
and the body can mantain itself for a longer period of time

its very possibly
so please be creative =)
without creativity and science fiction, science stands still and loses all of its amusing properties

 

[Parts Unknown]

You can't control your age and it's one of the largest factors in the cost of insurance because it makes sound actuarial sense. Your genetics should be no different.

That assumes an actuarial model is the best one to use (and for behavioral variables it may be). However, recall that Medicare exists because there is no way to privately insure people above a certain age at affordable rates.

Moreover, simply because you were sequenced does not mean that this information would be revealed to your insurance provider.

If it goes in your chart and is used to make treatment decisions your insurance company will have access.

 

[greatnt249]

what is usually science fiction
usually becomes reality

we've figured out that telemerase is the key to genetic stability and the sametime
genetic instability; cancer

its only a while until we modify telemerase and boom..
aging is gone
and the body can mantain itself for a longer period of time

its very possibly
so please be creative =)
without creativity and science fiction, science stands still and loses all of its amusing properties

Activated telomerase is also thought to contribute to cancer...just something to think about. Cell death is a necessary part of the continuation of life.

 

[Drrrrrr. Celty]

Activated telomerase is also thought to contribute to cancer...just something to think about. Cell death is a necessary part of the continuation of life.

which is why i stated right above it that there is genetic instability with it =p

but yah.. cell death is a contribution.. or else.. well
we'd explode from having constant cellular division without death