As a medical oncologist who entered the field when there were perhaps 50 or so active drugs, I have become increasingly disturbed by the rising costs of cancer care. Of course, I am not alone in worrying about this. A New York Times article last month highlighted the striking costs of drugs approved or in the pipeline to treat prostate cancer, my major area of research interest. There is an old aphorism in medical oncology that goes, “When cancer’s the answer, tissue’s the issue.” I wonder if there should be a new one, “If cost is the issue, cancer’s the answer.”
There are no easy answers to healthcare cost containment. However what is abundantly clear is that our medical industrial complex is rapidly surpassing the military industrial complex as a driver of our economic woes. The spending for healthcare in our beloved country is now twice that of other industrialized countries according to a Los Angeles Times article. Because of this, every widget produced here has a surplus charge that makes our workforce increasingly unable to make widgets in a global economy, since we have to pay for that worker’s healthcare costs in some way. When you try to get at the drivers of the problem, you end up with the nasty political debate that turns a reasonable discussion about the importance of discussing end-of-life care into “death panels” sound bites. Five of the 15 most expensive drugs on the market are cancer drugs. At the government level, patient advocates present emotional appeals for Medicare to pay for all of them.
So here are some inconvenient truths that we need to face up to:
1. Cancer is a disease of aging.
2. We are not immortal and will die from something—hopefully in a dignified, loving environment.
3. The molecular biology revolution and subsequent human genome understanding will make it possible to identify more and more driver mutations for each individual person’s cancer.
4. Our remarkable pharmaceutical industry can build designer drugs for each mutation, but the size of the market for each new targeted drug will be much smaller than just a cancer type.
5. Our system of capitalism is incentivized to maximize financial revenue to each entity in the healthcare system (hospitals, doctors, pharmaceutical companies, and insurance companies).
I think it is time for oncology physicians and their patients to begin to discuss these issues in ways that seek global answers rather than the individual problem facing his/her treatment choice. In my office, I can always think of one more long-shot drug to try in treating a patient with prostate cancer. But is it really fair to him or to our society to prescribe a vaccine that costs almost $100,000 and prolongs life by 4 months? What about using expensive cytokines to support white blood cells after cytotoxic drugs if the goal of treatment is palliation, not cure? Would it not be better to reduce the cytotoxic drug dose? And finally, since there are studies that show patients who receive palliative care counseling early in their disease process may live longer and better lives, shouldn’t we begin to focus on that rather than introducing another “miracle” life extending drug that actually adds only a few months of survival at the very end of a long life?
The 20th century provided mankind with the ability to understand diseases at the most fundamental level. Vaccination, cardiac care, early detection technologies, and remarkable improvements in cancer medicine allow most of us to live to the proverbial “3 score and 10, or even 4 score” years we are allotted. The 21st century seems to be asking whether we will ruin our collective selves seeking false immortality.