Only dead fish flow with the stream

In this world we see many fish. Most of what we see or know of are dead fish. Dead fish don’t flow against the current. They just float down with the stream.  Drs. Graeme Morgan, Robyn Ward and Michael Barton of Australia (see Part 2 & 3 of this article) are no dead fish – they flow against the stream. I salute them for having the guts to speak up.

Drs Tito Fojo and Christine Grady in the USA appear to swim against the current too. They wrote an interesting paper: How much is life worth: Cetuximab, non-small cell lung cancer and the $440 billion question. The first author is from the Medical Oncology Branch of the National Cancer Institute, Bethesda, USA, while Dr. Grady is from the Clinical Center, National Institutes of Health, Bethesda, USA.

Click here for the full version of their paper:  http://jnci.oxfordjournals.org/content/101/15/1044.full

Background

Today the world is still at war with cancer. Thus cancer is a big industry.  And “making magic bullets” for cancer is big business with extraordinary good profit. It was said that the year 2008 was one good year where “few major breakthroughs” in cancer were announced.  This was also the year when Erbitux (or cetuximab) was added to cisplatin and vinoreline as he “magic” drug to treat non-small cell lung cancer (NSCLC).

When Erbitux was first announced, researchers wrote : Erbitux or “cetuximab add to platinum-based chemotherapy sets a new standard for the first-line treatment of patients with NSCLC.”  Doctors were told: “these findings are likely to have a significant impact on the care of patients with these types of cancer.”  Those who read (blindly) would swallow this hook, line and sinker! Indeed we were then entering the age where we were about to defeat cancer!

Let us highlight some examples of the so-call scientific breakthroughs

•  Erbitux – increases survival in those with advanced lung cancer by 1.2 months when combined with chemotherapy.  This study involved over a thousand patients in 30 countries with advanced non-small cell lung cancer. Though 1.2 months may appear modest, this study offers hope for this group of lung cancer patients that have a 1-year survival rate of less than 50%.
•  A study in Spain by Rosell et al (Ann Onclo. 2008. 19(2): 362-369) involved 86 patients. Group A had 43 patients who received cisplatin/vinorelbine. Group B had 43 patients who received Erbitux plus cisplatin/vinorelbine.  The results:

1. Median progression-free survival is 4.6 months in A and 5.0 months in B. This means with addition of Erbitux the disease did not progress by 0.4 month (2 weeks?)
2. Median survival was 7.3 months in A and 8.3 months in B. This means with addition of Erbitux patients survived 1 month longer!

Drs Tito Fojo and Christine Grady wrote: “Unfortunately, the announcement of a 1.2-month prolongation of survival in NSCLC was not the first time Erbitux garnered attention for marginal benefits.”

The FDA approved Erbitux for advanced colorectal cancer after it was shown that when combined with irinotecan, Erbitux prolonged overall survival (OS) by 1.7 months compared with single-agent Erbitux but not with single-agent irinotecan.  (For those who understand a bit of science, this approval appears real “weird” – something is not right somewhere but we are not going to get distracted by this.)

This prolongation of 1.7 months survival came with skin toxicity in 85% of patients.

Drs Tito Fojo and Christine Grady asked: “Is an additional overall survival of 1.7 months a benefit regardless of costs and side-effects?”

To be fair, the authors are not just “gunning” at Erbitux alone. The FDA had also approved another drug called Avastin  –a rather well known and commonly used in this part of the world.  Avastin was to be combined with carboplatin and paclitaxel for first-line treatment patients with metastatic nonsquamous NSCLC based on an overall survival increase of 2.0 months.  As a result of this, addition of Avastin to chemotherapy then became the standard of therapy for nonsquamous NSCLC, despite disagreements among lung cancer specialists regarding the actual benefit.

Avastin is also added to chemotherapy for treatment of breast cancer. The benefit of Avastin for this breast cancer is probably nonexistent. Now, the US-FDA had withdrawn this approval.

In pancreatic cancer, the addition of Traceva (erlotinib) to gemcitabine improved overall survival by a mere 10 days (OS = 6.24 months vs 5.91 months).

Drs Tito Fojo and Christine Grady again asked: “Did the results of this trial constitute a breakthrough?”  They said: “But the only reasonable conclusion is that a magic anticancer bullet aimed at an important target missed by a wide margin.”

They asked:

• What counts as a benefit in cancer treatment?
• How much should COST factor into deliberation?
• Who should decide?

How much is life worth?

The above is an abridged version of Table 1 in Dr. Fojo & Grady’s paper and these are what they said about cost:

1. In the United States, Treatment with Erbitux treatment for lung cancer costs an average of US$80,000 (to prolong life by 1.2 months), which translates into an expenditure of US$800,00 to prolong life of one patient by one year.
2. The median US household income is US$50,233.
3. The cost of Avastin treatment is US$90,816 and that is said to prolong life by 1.5 months.
4. The cost of Tarceva treatment is US$15,752 and it is said to prolong life by 10 days.
5. The cost of Nexavar treatment is US$34,373 and it is said to prolong life by 2.7 months.
6. Greater than 90% of the anticancer agents approved by the FDA in the last 4 years cost more than US$20,000 for a 12-week treatment.
7. These examples challenge the oncology community to address some serious questions:
8. What should count as a benefit in cancer?
9. What is the minimum amount of benefit needed to adopt a therapy as the new standard?
10. Is 1.2 months of additional life a “good” in itself?
11. How much should the quality of that 1.2 months matter? Or the cost?

(Take note: none of these drugs cure cancer. They just prolong life by just a few days or months)

Comments 

It Costs US$350,000 to Die of Cancer in America Today 

By the time you add up the costs of surgery, radiation, chemo, hospitalization, hospice care, etc., it costs about US$350,000 to die of cancer in America.

Of course, the conventional modern medical treatments might work. As Julian Whitaker, M.D., told me, radiation and chemotherapy are dangerous placebos. And placebos sometimes work ~ Frank Cousineau, President, Cancer Victors, Cancer Breakthrough USA.

For more click this link: http://cacare.com/index.php?option=com_easyfaq&task=cat&catid=109&Itemid=39

• It Costs US$350,000 To Die of Cancer in America Today
• Extremely High Cost of Chemo-drugs
• Iressa Expensive Drug With Side Effects
• Obscene Drug Markups
• Repair Cost Higher Than Actual Treatment Cost

In concluding their paper, Dr. Fojo & Grady wrote:

• The all too common practice of administrating a new, marginally beneficial drug to a patient with advanced cancer should be strongly discouraged.
• In cases where there are no further treatment options, emphasis should be first on quality of life and then cost.
• For therapies with marginal benefits, toxic effects should receive greater scrutiny.
• We must deal with escalating price of cancer therapy now.
• The current condition cannot continue … the time to start is now.

Earlier, Dr. Fojo & Grady also cautioned that: “As oncologists, we cannot go without answering these questions. The moral character of our specialty depends on the answers.”

Indeed, I am really glad that moral value or character is now being suggested here! Let us talk less about money, more of moral values.

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The Economist of 26 May 2011 had an article entitled: The costly war on cancer – New cancer drugs are technically impressive. But must they cost so much? http://www.economist.com/node/18743951?story_id=18743951

The article says:

• CANCER is not one disease. It is many. Yet oncologists have long used the same blunt weapons to fight different types of cancer: cut the tumour out, zap it with radiation or blast it with chemotherapy that kills good cells as well as bad ones.
• The snag, from society’s point of view, is that all these drugs are horribly expensive.
• Not all these new drugs work.
• In December the FDA said that Avastin’s side effects outweighed its meagre impact on breast cancer.
•  More generally, some people reckon that new cancer drugs offer small benefits at an exorbitant price.
• Provenge (for advanced prostate cancer) costs $93,000 for a course of treatment and extends life by an average of four months.
• Yervoy (for melanoma, a kind of skin cancer) costs $120,000 for three-and-a-half months. Some patients live much longer, which fuels demand for the drugs. But others spend a lot and get little.
• Who will reform this unsustainable system?
• Last year Gleevec grossed $4.3 billion. Roche’s Herceptin (the HER2 drug) and Avastin did even better: $6 billion and $7.4 billion respectively.

My comment: At the end of it all – it is about making huge profit at the expense of helpless cancer victims.