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Why is Cancer so Expensive?
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Released: June 13, 2024

John Marshall
John Marshall, MD
Catch Up On All Episodes of Oncology Unscripted

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ASCO Wins 

[00:04:17]
Let's start with looking at the success, amazing success, of the clinical research that was presented at ASCO. There were three standing ovations among the five plenary abstracts that were presented, and the one that probably deserved it was a drug called osimertinib. You know, this is for EGFR-targeted non-small cell lung cancer. And the benefit was dramatic. A huge delta between the curves. And all of a sudden, everybody said, this is the way to go. I think probably yeah, there's a terrible disease. It's a therapy that works very, very well. Huge improvement in outcome for patients in the curative setting. All in, right? We're all in in that group. Worth standing up and clapping for.  

But, did you know that the rumor is, a little gossip, that, uh, that the other two standing ovations also, drug therapy studies were actually started by plants from the companies who wanted everybody to stand up for their therapies as well. I hope that's not true. I really hope that's not true, but it might be. You never know. Could be true that they're trying to get more standing ovations to applaud this victory that everyone is claiming that we have in cancer.  

[00:05:40]
I can't resist telling you about one other study was done in colon cancer. My baby. A study that could only be done, where they have the best COVID, in France. This was a study led by a brilliant surgeon who has set so many standards for us all around the world, a guy named Rene Adam. And believe it or not, liver only metastatic colon cancer, half the patients got standard chemotherapy, The other half got a liver transplant. Do you think you could ever do that study here in the United States? No way. There is no way you could ever do that study here. What patient would allow you to randomize them to a transplant over there or continued chemotherapy over there? If you were eligible, I want that transplant, baby. I'm American, I can have whatever I want. They pulled it off over in Paris, and what they were able to show is again a dramatic difference for the transplant. Something like 70% versus 15%, a huge delta between the two groups. And even though it was a small study, it was very well done, very well, conceived and followed correctly. So, setting a new standard for in the right patient liver transplantation for metastatic colorectal cancer.  

Clinical Research Reality Check 

[00:06:55]
This has made me reflect a bit about clinical research in general. What is the value of clinical research? Well, one of our lines has always been that if you're on a clinical trial, you live longer; that somehow patients who participate in clinical research live longer. 

There was a recent paper that was in JAMA that actually did this. They took a bunch of studies, and they pulled it apart and they actually did show that there was some benefit to being on a clinical trial. So, you're okay in saying that, but then the authors went a little bit deeper and actually compared it to what if you were on standard therapy, and, if they pulled out those clinical trials where the control arm or whatnot was a standard therapy that was in place right now, there wasn't any survival advantage. So, it was only when you compared it against other kinds of approaches that people showed that survival advantage. So, it was a little bit of a mixed message of, yeah, there's a survival, but maybe not so much as we thought before. That was a little bit of water on our flame.  

[00:08:03]
And then a second approach that was, was presented in Cancer Medicine actually looked at how we've done not a very good job of increasing accrual to clinical trials. There are all sorts of strategies and studies and education and all of this that we've done to try and increase awareness of clinical trials; increase participation in clinical trials. And, yet we really haven't made too much out of that.  

So, on the backdrop of all of that, we’ve still got a lot of work to do. I don't think we have a victory just yet.  

Drug Price Negotiations 

[00:08:41]
Let's get back to this value question. You may not know that there's a law in the United States that says, I can't judge value. I can't put together the cost of something and the magnitude of benefit. We're the only country in the world that has this law. And so, to begin to undo that law. A year ago, the folks from the government said, we're going to put out 10 drugs. We're going to give you a list of 10 drugs that we would like to negotiate price on. And we want to start this discussion. Well, lots of people said, this is never going to go. It wasn't just cancer drugs, but some of them are cancer drugs. People said, this is never going to happen. We're not going to have that discussion. It's just going to go away. There's too much going on that’s good with the way the current system works. So, we're not going to mess with that.  

The reason this has come back to mind is that it didn't go away. Just about a month ago here near me, in Maryland, the state legislature had a meeting. They put together a committee and had a meeting. And in this case, they picked eight of those ten drugs, and they began to talk about how are we going to think about this. Now, I worry a little bit because who's on this committee? Who's making this decision? Well, we do have people from the pharmaceutical industry, we have insurers on that, we have medical communities, and unions, and patient representatives, etc. So, you know, probably pretty good representation to discuss the impact of should we or shouldn't we. And you must remember that Maryland is quite, I don't know if you want to call it progressive, but it's out there with regard to government healthcare, has completely different laws around Medicare than any other state in the country. They might just take this on and think about it in more detail. 

You know who I really find missing in all of this discussion is the payer. So where is Medicare on a huge pot of money over there? Where are the Blue Crosses and Blue Shields in all of this discussion? Because the way I think about it, we are each paying into those banks, whether it's Medicare or your own health insurance company. Each month coming out of your paycheck, taxes going into those banks, and you haven't gotten a raise in a while because companies are putting in more and more on our behalf. So, the bank's getting filled up, and then they guard it. The insurance companies guard the bank, but distribute it to people as they need it. And that's the model of insurance, of course. We hate our insurance companies because they're always fighting. We don't like the way they guard that bank. We want them to let everything out of there if they can. But on the flip side, we don't want our individual costs to rise. So, we kind of talk out of both sides of our mouths.  

I've been thinking like a crazy idea. Go with me on this. What if you just got diagnosed with, I don't know, say metastatic colon cancer? And your insurance company calls and says, sorry, you've got metastatic colon cancer. We'll offer you today half a million dollars, five hundred thousand dollars cash, to not take treatment. Would you take the money? Who out there would take the money? I see you. Who out there would not? Turn it down and take treatment? Because in fact, we're about to spend more than half a million dollars on you. And so, I never understood why insurance companies don't offer you a buyout to get out of all of this and just pay some cash and go, but that's never going to happen. We know that.  

So, we are in fact having the discussion. We probably will over time begin to whittle away at this concept of negotiating drug prices so that that component of our over-expensive health care system can at least fall into line. That yes might make for less fancy booths at ASCO. We're going to have to realize that you won't be able to get quite as good a cappuccino at that favorite drug company booth that you got when you were in Chicago this past weekend. But I think we'd be willing to make the trade for, some sort of better pricing, better access to drugs, in our country and around the world.  

I want to shift gears to a really, I think, even bigger problem than the expense of new drugs. Because one of the arguments that the companies make is that clinical research has gotten really, really expensive. 

And there's a law that you might know about sort of a theoretical law called Moore's law, that I think, came around building computer chips, that with every year, with every five years, it not only got cheaper to build the chips, the chips got dramatically better. They could hold more data, they were faster, etc. So, that Moore's Law of it gets cheaper and faster, is how much most things work in the development world. Well, in drug development, jokingly, they call it Eroom's Law, it's Moore's Law backwards. And essentially this says that with each passing year, it is getting more expensive and less efficient to do clinical research. And this has been going on, as an old guy, this has been going on for gosh, 10, 20 years. 

We thought we'd do is deep dive into this subject, and we have invited maybe one of the brightest people on the planet with regard to clinical research. And not only smart about it, but is determined to do something about it.