Cancer's cost: Doctors urged to talk dollars

By Helen O'Neill
10,april,2008--WASHINGTON — You've just been diagnosed with cancer, and the doctor is discussing treatment options. Should the cost be a deciding factor?
Chemotherapy costs are rising so dramatically that later this year, oncologists will get their first guidelines on how to have a straight talk with patients about the affordability of treatment choices, a topic too often sidestepped.
"These are awkward discussions," said Dr. Allen Lichter of the American Society of Clinical Oncology, which is writing the guidelines. "At least we can bring this out in the open."
It's a particular issue for patients whose cancer can't be cured but who are seeking both the longest possible survival and the best quality of life — and may be acutely aware that gaining precious months could mean bankrupting their families.
The prices can be staggering. Consider: There are two equally effective options to battle metastatic colon cancer, the kind spreading through the body — but one costs $60,000 more than the other, said Dr. Leonard Saltz of Memorial Sloan-Kettering Cancer Center.
What's the difference? The cheaper one, irinotecan, causes hair loss that makes it impossible for people trying to keep a job to hide their cancer treatment, he explained. The pricier oxaliplatin can cause nerve damage in hands and feet that might make it a worse option for, say, a musician or a computer worker.
Saltz offers a tougher example: A drug for pancreatic cancer — an especially deadly cancer with few treatment options — can cost $4,000 a month. Yet while Tarceva has offered some people remarkable help, research suggests that extra survival on average is a few weeks.
"Is it a good investment, a high-risk investment, or buying a lottery ticket?" is how Saltz put these choices.
Drug prices are a growing issue for every disease, especially for people who are uninsured. But cancer sticker shock is hitting hard now, as a list of more advanced biotech drugs has made treatment rounds costing $100,000, or even more, no longer a rarity. Also, patients are living longer — good news but meaning they need treatment for longer periods. The cost of cancer care is rising 15 percent a year, Lichter noted.
Make no mistake: Some of these newer drugs have greatly helped some patients. Gleevec, for example, has revolutionized care for a type of leukemia — and the prices reflect manufacturers' years of research and development investment.
Also, drug companies do donate a certain amount of medication to prescription-assistance programs that provide them free to patients who otherwise couldn't pay. Since 2005, nearly 5 million people — cancer patients and people with other diseases — have been matched to such programs through the drug industry's Partnership for Prescription Assistance.
But few patients get a Gleevec-style home run, and there's very little research that directly compares competing treatments to guide cancer patients on which might offer the best shot at survival for the money.
"As long as a therapy provides a benefit, it will tend to be offered to patients. Whether it's a small benefit or a moderate benefit, it may be offered with the same level of enthusiasm," said Dr. Neal J. Meropol of Philadelphia's Fox Chase Cancer Center, who is leading the panel writing the Society of Clinical Oncology's new guideline on how to weigh treatment costs.
The idea: treat cost essentially as another side effect to weigh in choosing a therapy. Meropol has watched patients do those calculations on their own, like the colon-cancer patient who asked to switch from oral chemo to cheaper but more laborious intravenous chemo, or the woman who refused a pricey anti-nausea drug that would make her chemo more bearable.
But even if doctors want to discuss cost, they may not know it — it's not included in treatment standards.
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