The conversation about keeping U.S. health care costs under control has oscillated from maddeningly vague to absurdly detailed, but with no real plan emerging. The main reason for this, I believe, is that whenever the topic of cost control comes up, industry (pharma, hospitals, physicians, etc) starts to holler about rationing.
I’m about to say something really controversial here: a little rationing would probably be a good thing in many ways. Let me give an example.
In 2007, the FDA approved a drug called ixabepilone for the treatment of metastatic breast cancer. This approval was based on research like this study. In this research, we see that the average progression-free survival improved by a little more than a month when the new drug was added to an old regimen.
Of course, adding another medication leads to an increase in potential toxicity. In this case, we at least three times as high an incidence of severe neuropathy, fatigue, and low blood counts with the additional medication. Most alarmingly, we saw an increase in treatment-related mortality from 1% to 3% with the additional medication.
So, on the balance, we are trading a month delay in disease progression for a number of significant side effects. And one in fifty people to try the more aggressive treatment will be killed by it. Since these clinical trials tend to have aggressive exclusion criteria that push numbers toward better survival (e.g., they often exclude things like brain metastasis and abnormal liver or immune function), that month delay in disease progression is probably a best-case scenario.
Does that sound like a good risk / benefit trade-off? Now consider that the second medication adds $30,000 to total treatment cost. It shouldn’t be a big surprise to hear that the European regulatory agencies rejected this medication based on the same available data.
I don’t mean this specific example in any way to be a rant against conventional medicine treatment of cancer. It could just as easily have been chosen from any number of medical specialties. I have been thinking about the issue of expensive end-of-life care a lot over the last week after seeing this week’s Newsweek magazine cover story (The Case For Pulling the Plug On Grandma!). I’m really hoping that somebody will soon summon up the fortitude to start talking about this issue, not just in oncology journals, but in the public square.
Here’s a thought experiment for anybody who has made it this far: if I had a CAM therapy for cancer that cost $30K (more than the median income for a single adult in my state), had significant toxicity, and best-case scenario added a month to life expectancy, would you consider me a hero or a charlatan? From the other direction, is it a noble or cruel thing for doctors to offer a very expensive and dangerous treatment to a dying patient knowing that it has at best a marginal effect?