Combination Therapies: A Tipping Point for Cancer Drug Costs?

Leonard B. Saltz, MD


November 09, 2017

Hello. My name is Leonard Saltz. I'm a medical oncologist at Memorial Sloan Kettering Cancer Center in New York. I am chair of the GI oncology group as well as chair of the hospital's pharmacy committee.

This question often comes up: At what point will we reach a critical tipping point where we can't afford to provide the therapies that we want? This is becoming a problem as we start to think about multiple combination therapies, either combinations of novel immuno-oncology agents such as checkpoint inhibitors, novel targeted agents, or a combination of targeted agents and checkpoint inhibitors.

When I talk about drug prices being unsustainable, nobody argues with that anymore.

All of these agents are coming onto the market with price tags that are often running in excess of $150,000 per year. That's just the cost of an individual drug. If we now have two or three drugs in that price range, and then we start to consider the supportive care medications—and this is before we even get to the costs of the doctor's fees, nursing fees, pharmacy fees, the cost of taking care of the complications, and the potential costs of hospitalization—it's easy to see how these prices can spin out of control very quickly.

When I talk about drug prices being unsustainable, nobody argues with that anymore. There's general agreement that we can't sustain the current practices in drug pricing. The question is: How do we deal with it? What does unsustainable mean? It means that it's going to fall apart in some way. If we don't find a way to let it down gently, the only logical assumption is that it's going to very suddenly crash one day.

We're going to have to look at cost and value. We're going to have to look not only at the actual dollar amount that's being spent on a drug but the dollar amount being spent on the overall therapeutic plan and the incremental benefit that is realistic for the patient to expect to receive. We may have to make some very difficult choices for something that is dramatically more expensive [and] maybe just a little bit better.

The low-hanging fruit is looking for those circumstances where something is dramatically more expensive and no better. There's an interesting article recently in JAMA looking at treatment for macular degeneration with vascular endothelial growth factor inhibitors—a comparison of bevacizumab versus aflibercept where the bevacizumab dose costs $60, and the aflibercept dose costs $1800. Noninferiority was achieved in the clinical trial, suggesting that it would be reasonable to use either one. Those kinds of studies are doable and need to be done in oncology; we're going to need to look at expensive versus less expensive options. We need to consider who, if anyone, can be treated with the most expensive [option] and where those more expensive ones might not be value added for certain types of cancers or certain stages of cancer.

We're going to have to risk stratify and figure out how to get the most benefit to our patients in a cost-effective manner in order to be able to provide all of the patients who need [cancer treatment] with the drugs that they need.


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