In January 2023, we have seen biotech layoff a small percentage of their workforce citing “pressure on drug price and inflation”. In light of this, it is imperative to visit the state of drug prices, particularly around a sky-rocketing market such as cancer treatments.
The shifted paradigm of cancer treatment to targeted therapeutics has been associated with a drastic increase in the price of anticancer drugs. Novel biologic therapies may cost upwards of $10,000 per month, which is double the US median monthly household income. Medicare Part D patients on anticancer drugs can accumulate as much as $16,000 out of pocket cost each year. Although this cost offsets years of research and development, it further exacerbates cancer health and socioeconomic inequities. Not only do rising prices foster financial toxicity for low-income individuals, but they also augment the complexity of a physician’s assessment of a “value” therapy. There are three perspectives that are impacted and need to be shifted in response to rising anticancer drug prices.
Oncologists must consider many variables when assessing the value of a treatment. From a clinician’s standpoint, it is possible to view the value of the therapy from a cost (including time, travel, etc), clinical, and/or societal standpoint. Clinicians must be careful to prevent a single factor from overwhelming their evaluation of a therapy. If an oncologist recognizes that their patient population consists of low-income individuals, it is appropriate to evaluate a therapy with cost as a larger factor to cater to the population. This may cause clinicians to modify their care goals and inadvertently base care on socioeconomic status. A patient might be looking for a small chance of remission, which the physician would have never considered or offered due to the price of the therapy. On the other hand, if an oncologist bases care solely on clinical benefits, they run the risk of leading their patient into a strenuous financial predicament. Clinicians simply using societal costs to influence their treatment decisions is shown to be disfavored by patients.
So, the peculiar position of an oncologist is that the value of a therapy from their perspective is slightly arbitrary. Each oncologist can define the value of a treatment differently from patients, which may result in a negative patient experience. It is important to recognize and consider a patient’s financial position, but decisions should be based on the discussion of the clinical care goals and the patient’s preferences on how to deal with them. Moving forward there must be discussion of what is valuable to a patient, regardless of any cost barriers, rather than considering price as part of the benefits and drawbacks of certain therapies.
With novel therapies, patients seemingly have a diverse selection of treatments that can be tailored to the unique molecular anomalies of their illness. However, the value-based implications of suitable treatments, assessed by their physician, can draw patients into a confusing, overwhelming decision network. Patients must consider the possibility of losing efficacy or possible remission while being careful to avoid the lasting damage of financial toxicity, all while burdened by their illness.
There is a large divide in information on the benefits and drawbacks of health care decisions and the possible solutions for patients. A patient may accept the risk of economic hardship from a “high value” therapy determined by their physician but are unable to adhere to it, due to financial distress affecting the patient’s well-being and families. Cost-related nonadherence (Skipping prescription refills to lessen co-pays, taking less than prescribed, etc) is fairly common in oncology and accumulation of financial stress may encourage patients to stop expensive life-prolonging therapies compared to those with lower copayments.
If there were transparency in a patient’s preferences and financial situation with insurance covered cost and direct costs, an oncologist could utilize a social worker to aid the patient in connecting with a fee-assistance program or pharmaceutical assistance. The medical price transparency law is another step forward in assisting patients to understand and communicate their preference on treatment decisions. However, the low rate of reporting along with price variability between institutions and insurers, specifically in oncology, needs to be improved through changes in regulation to aid patients in understanding their financial position with respect to their therapeutic decisions.
Patients rely on their physicians as advocates of appropriate care, based on their preferences. When cancer patients are asked to define clinical value, they tend to incorporate their communication and relationship with physicians. Without guidance and discussion, patients are thrust into a complex decision network that can be simplified with discussion around individualized, value-based care with their clinician.
Rationally, the principal determinant of anticancer drug prices is the cost of research and development (R&D), more specifically, recouping the expenses of failed, investigated drug candidates during the pre-clinical or clinical phase. It is paramount for cancer researchers to answer questions regarding the optimal strategies in addressing the cost of R&D. Utilization of machine learning during the drug discovery, pre-clinical and clinical phase can increase the success rate of drug evaluation. Even incorporating human genomic data into pre-clinical studies can rapidly improve drug development success rate and reduce R&D cost.
Researchers must be careful to not mistake innovation as progress in diverse patient populations. Biotech’s general philosophy is that of pushing innovation and progress. Breaking through scientific boundaries to provide patients with the highest-quality drugs needed. For example, Gleevec was inspiring to the oncological field, exhibiting high efficacy for certain mutations of chronic myeloid leukemia, and changed the landscape of cancer therapeutics. These kinds of breakthrough drugs and philosophies drive the oncological research space.
While the drive for innovation around cancer treatments is necessary, therapies need to be deployed with care, in an equitable manner, to achieve total progress for all patient populations. Supplemental research must be done to clarify the definition of value, similar to ICER’s use of Equal Value of Life Years Gained (evLYG), which removes bias from the academic standard quality-adjusted life-year (QALY). evLYG calculations are required to stop unnecessary upward price drift while encouraging R&D to focus on high-value drugs. This research is pertinent in equipping clinicians and patients with information to navigate the network of possible treatments.
Rising prices of anticancer drugs places stress on patients to deal with the risk of economic hardship and accentuates the complexity of a physician’s assessment of an appropriate, value therapy. Patients communicating their financial position while considering the supplemental data on the value of each drug can simplify a physician’s assessment and decision-making surrounding treatment plans.
Anshul Rao is an undergraduate student in the Department of Molecular, Cellular, and Developmental Biology at the University of California, Santa Barbara.