JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L Soaring Cost of Cancer Treatment: Moving Beyond Sticker Shock Cary P. Gross, Yale School of Medicine, Yale University, New Haven, CT Abbe R. Gluck, Yale Law School, Yale University, New Haven, CT See accompanying article on page 319 In Seligman’ s famous series of experiments, two groups of dogs were shocked at random intervals. 1 Dogs in one group could stop the shocks by pressing a lever. The other group had levers, too, but they were ineffectual. In the face of repeated shocks, those dogs soon showed signs of learned helplessness—resigned to their fate. Cancer specialists might empathize. The steady rise in the price of cancer drugs has produced its own series of shocks, in the form of persistent outcry and concern among patients, providers, and payers. Despite the plethora of proposed payment schemes and endless policy responses, for the most part, nothing has changed. With so much talk and so little action, one wonders how and whether the medical and policy communities will continue to re- spond to sticker shock. Will we tire of the talk and become so inured to the problem that we render ourselves helpless to effect change? Against this backdrop, the meticulous study by Gordon et al 2 highlights an important aspect of drug pricing. Although there has been abundant literature regarding trends in the launch prices of new cancer treatments, less is known about the pricing trajectory of individual drugs over time. Gordon et al observed a cohort of 24 injectable cancer drugs for 8 years after US Food and Drug Administration approval and found that the average drug price increased by approximately 18% during those years. Notably, the cost trajectory was not affected when a competing drug entered the market, reinforcing differences between the pharmaceutical market and traditional competi- tive markets. The pharmaceutical industry is a major driver of research and innovation in cancer. Patients with cancer directly benefit from its efforts and products. 3,4 However, there is also cause for concern. Thanks to work such as the Gordon et al 2 study, the body of evidence regarding the cost of cancer therapies and the effect on patients has become increasingly robust. For instance, we know that the cost of cancer drugs has increased dramatically, despite the fact that most drugs are brought into the market without com- pelling evidence that they prolong survival or improve quality of life. 5-9 We know that these high costs render state-of-the-art cancer treatment unaffordable to patients without insurance and even to some patients with insurance. 7-9 Furthermore, financial distress associated with paying for cancer treatment is common and is associated with stress, decreased adherence, bankruptcy, and worse outcomes. 7,9-14 Finally, we know that the cost of new drugs is not well correlated with their effectiveness, nor with the presence of competing products. 15-18 Where do we go from here? One finding from the analysis by Gordon et al 2 provides some helpful insight; there was a single instance when the cost actually decreased after a new drug was launched on the market—the high-profile case of ziv- aflibercept—which was initially approved for metastatic colon cancer in 2012 and priced at approximately $11,000 per month. 19 The price of ziv-aflibercept declined by approximately 13% in the 3 years after launch after physicians at Memorial Sloan Kettering indicated that they would not be using the drug. 20 This anecdote is informative because it highlights how three commonly touted policy levers can work effectively—transparency (the provider had information about the costs and relative benefits of ziv-aflibercept), choice (other equally effective treatment choices were available), and leverage (the provider in this case, as a market leader, had enormous leverage to negotiate). However, more than anecdotes about the pricing of a single drug are needed at this point. It is time to summon the political and professional will to implement and evaluate the best policy options for addressing the high cost of cancer drugs. The most obvious course of action—and likely the one that will be the most effective in the long run—is federal policy change. This option, however, faces enormous political obstacles, given that we are in a moment of historic congressional gridlock and that consensus on health policy has been difficult to generate even in the most collegial of legislative times. Indeed, even before the current political moment, the fed- eral government has proved a disappointing partner in piloting ex- periments related to drug pricing. During the Obama administration, the Centers for Medicare and Medicaid Services proposed a pilot program to address the perverse incentives to prescribe high-cost treatments in a fee-for-service system by testing value-based pur- chasing for drugs covered under Medicare Part B, such as chemo- therapy. 21 However, this experiment could not get off the ground in the face of enormous backlash from the pharmaceutical industry and provider groups. 22 Another attempt to change a potentially detrimental policy—the provision in Medicare Part D that requires its drug plans to give access to all or nearly all drugs on the market in six protected classes, including cancer drugs—was likewise stymied. 23 Notably, this was a much less radical change than the oft-suggested reform of repealing the Medicare ban on negotiation, which still got nowhere. Journal of Clinical Oncology, Vol 36, No 4 (February 1), 2018: pp 305-307 © 2017 by American Society of Clinical Oncology 305 VOLUME 36 • NUMBER 4 • FEBRUARY 1, 2018 Downloaded from ascopubs.org by 54.166.130.188 on December 16, 2022 from 054.166.130.188 Copyright © 2022 American Society of Clinical Oncology. All rights reserved.