June 30, 2009 The decision to use expensive cancer therapies that typically produce only a relatively short extension of survival is a serious ethical dilemma in the U.S. that needs to be addressed by the oncology community, according to a commentary published online June 29 in the Journal of the National Cancer Institute.
Tito Fojo, M.D., Ph.D., of the Medical Oncology Branch, Center of Cancer Research at the National Cancer Institute, in Bethesda, Md., and Christine Grady, Ph.D., of the Department of Bioethics, the Clinical Center at the National Institutes of Health, tackle the controversy concerning the life-extending benefits of certain cancer drugs and the extent to which their cost should factor in deliberations.
The authors illustrate cost-benefit relationships for several cancer drugs, including cetuximab for treatment of non-small cell lung cancer, touted as "practice changing" and new standards of care by professional societies, including the American Society of Clinical Oncology.
They ask, "Is an additional 1.7 months [the additional overall survival for colorectal cancer patients treated with cetuximab] a benefit regardless of costs and side effects?"
According to Fojo and Grady, in the U.S., 18 weeks of cetuximab treatment for non-small cell lung cancer, which was found to extend life by 1.2 months, costs an average of $80,000, which translates into an expenditure of $800,000 to prolong the life of one patient by 1 year. At this rate, it would cost $440 billion annually, an amount 100 times NCI's budget, to extend the lives of 550,000 Americans who die of cancer annually by 1 year.
To address the issue, the commentators recommend that studies powered to detect a survival advantage of two months or less should test only interventions that can be marketed at a cost of less than $20,000 for a course of treatment.
Every life is of infinite value, the authors say, but spiraling costs of cancer care makes this dilemma inescapable.
"The current situation cannot continue. We cannot ignore the cumulative costs of the tests and treatments we recommend and prescribe. As the agents of change, professional societies, including their academic and practicing oncologist members, must lead the way," the authors write. "The time to start is now."
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- Fojo T. and Grady C. How Much Is Life Worth: Cetuximab, Non-Small Cell Lung Cancer, and the $440 Billion Question. J Natl Cancer Inst, 2009; 101: 1-5
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