Wasted Cancer Hope

In a Post oped, a cancer doc admits to impotence:

My patients seek state-of-the-art therapy. … Almost all of them have insurance, … their access to care is virtually limitless. We employ the latest [everything] … Yet, despite the many recent advances in detection and treatment, of the 50 patients, 40 of them are likely to lose the fight. … When it comes to cancer care, we’re not getting what we pay for. … Few cancer clinical trials are designed to “cure” patients. They are commonly aimed at … an extension of average survival from 5 months to 6 months. ..

Globally, cancer care is a medical luxury. With some diseases such as colon cancer, the treatments alone cost more than $15,000 a month, yet on average add only a few months to survival. Most poor countries do not support any cancer care; most developed countries highly restrict it because of its cost and limited effectiveness. The United States is the only place on Earth with relatively unfettered access to cancer care, including the latest medicines, sophisticated scans and high-tech radiation, all of which are very expensive. But despite their more limited access, cancer patients in other high-income nations may live longer and with a higher quality of life than patients in this country. …

I frequently ask my students and peers if there is a cancer drug today that they would pay for out of pocket if they had to. … After a long pause, someone invariably will say “Gleevec,” … a true magic bullet. Very few cancer drugs can be described as having this kind of value.

Amazingly, he concludes:

Oncologists are optimists, and I am proud to be among them. I truly believe we can cure cancer. I care greatly for my patients and am doing everything in my power to improve and lengthen their lives. When I offer a clinical trial to a patient, I am hopeful that it will be better than the standard treatment. I am optimistic that health-care reform will not simply provide everyone with insurance that will cover the “standard of care” but will also force us to determine the true value of treatments.

This gives “optimism” a bad name.  He admits his profession wastes vast resources selling false hope, but we are supposed to let that slide because he is proud to be “hopeful”?

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  • Carl Shulman

    “After a long pause, someone invariably will say “Gleevec,” … a true magic bullet.”

    This is indeed an excellent drug.

  • Are there insurance plans available which do not pay for expensive cancer treatments?

    He may give “optimism” a bad name regarding his own patients, but the idea that health-care reform will force us to restrict access to cancer care does not seem like a completely false hope.

  • Prostate cancer screening, detection, and treatment is the cash cow of American urology. One can find support for any approach imaginable in the vast collection of published studies about this disease that kills about 200,000 Americans annually. This past year, two comprehensive studies were published summarizing 10-year survival rates of men diagnosed with prostate cancer. The category of “no treatment” was as good as any other regimen, and better than some. The reference trail is complex, but one could start here to trace sources, including this one.

    • Grant

      It would be really nice if there was a site dedicated to burrowing through medical statistics and informing the patient. Even if an insurer or the government is footing the bill, most health care treatments are not fun, especially cancer treatments. I think its safe to say many patients would love to know if “do nothing” is a viable option.

      Are you saying most prostate cancer treatments aren’t worth doing? What sort of prostate cancer is worth treating?

      • Are you saying most prostate cancer treatments aren’t worth doing?

        No, the statistics say that. E. Yudkowsky once aimed a comment at me when I argued medical experience against statistics: “I don’t think you understand what statistics mean. They are not a sort of weak extra argument that you weigh in addition to your much more reliable personal experience; statistics are a stronger, more reliable way of looking at the world that summarizes far more evidence than your personal experience, even though it just looks like a little number on paper while all that other experience weighs so heavy in your mind.”

        I took note.

  • Having worked down the hall from the neurosurgery department of a major hospital, I’d reluctantly say that there’s a lot of truth here. What always boggled my mind was the patients who would submit to a debilitating procedure just to get a few more months.

    The question, of course, is “would I do differently?” If I were paying out of pocket and directly impoverishing my family and reducing my children’s inheritance (rather than indirectly doing so through contributing to the Medicare crisis), the tradeoffs would be much more apparent.

  • bcg

    Imagine we shut it all down today because it is deemed too wasteful. If there is ever a “cure” for cancer invented, this probably delays that invention. Do you have an alternative scheme to incentivize cancer research? Do you see that delay, when discounting is applied, as worth it? If not the delay alone, do you see other considerations, some positive and some negative, and making it worth it?

    • Emmett

      What about incentivizing cancer research directly, say by offering prizes for drugs of certain efficacy? Why do we need to waste a bunch of money using “cancer cures” that don’t work in order to incentivize the creation of cures that do?

    • Psychohistorian

      This assumes that the current incentives are conducive to finding a cure, which they aren’t really. A magic pill that could cure cancer would cost the industry a lot of money, particularly since government would likely intervene to prevent such a drug from being priced too high for most to afford.

      More practically, though, current reasearch is dedicated to life-extension, which may or may not be conducive to actually curing cancer. If life extension weren’t covered as generously, it seems likely that research would change its focus towards either elimination or prevention, as both would be more marketable. Or it would just drop the subject entirely, which is admittedly a risk.

  • Bill

    Whose cancer–mine or yours?

  • He says specifically why he is hopeful: the rise of personalized medicine based on a molecular genomic analysis of individual cancers. This is indeed a positive development, since until very recently there was no way to get a mechanistic understanding of the genetic disruptions involved in an individual’s cancer. It used to be a mystery why some patients would respond to a drug and others would not; we are beginning to be able to classify cancers into subtypes based on which genes and pathways are affected and base therapies on what is actually going on.

    • anon

      Yes. Note that the “magic bullet” drug mentioned in the editorial, Gleevec/imatinib, is an enzyme inhibitor which was specifically targeted to a specific chromosomal abnormality. This is why it works so well.

  • drc

    I’d like to be able to sign up for insurance that places limits on cancer treatment. I think it would be a great way to save money.

  • Bill

    People should put their money where their mouth is.

    Some insurance carrier should offer an insurance policy with a reduced rate for persons who agreed to decline medicine/treatment unless there were a probability of X% success as determined by a pre-negotiated panel composed of Mayo, John Hopkins, etc.

    Would people buy the policy? Or, would they decline it and be willing to pay a higher price because, when it is them, probabilities are personal. Don’t know, but we could create or offer such a product.

    • Psychohistorian

      This is an excellent idea generally, but implementation would be a nightmare. I would certainly consider waving certain treatments (particularly when I’m old). But selecting a health care plan is already nightmarishly complicated (if your employer doesn’t do it for you), so adding an additional rule like this seems like it would invite confusion and probably lawsuits.

    • In some cases there are laws mandating coverage for certain things. I have no idea if cancer drugs are one of those things.

    • I strongly expect that, just like everything else that should be done to fix healthcare, this is illegal.

  • Chuck

    Well, lots of soft-headed sentiment there, but nevertheless, I think the final sentence is an optimism-worthy notion:

    “I am optimistic that health-care reform will not simply provide everyone with insurance that will cover the “standard of care” but will also force us to determine the true value of treatments.”

    Health care reform will likely define the standard of care as well as expand it to nearly all.

    Health care reform may force us to determine the value of treatments – note that in other countries with broad public-subsidized coverage, costs are much lower than here. (The govt isn’t incentivised to sell hope over outcome as private care is.)

    I agree with the comment along the lines of ‘shouldn’t/wouldn’t it be great if private plans offered coverage that excludes certain/most cancers and costs significantly less’. Makes me wonder if the savings per person would be significantly less…

  • Jess Riedel

    First, $15,000/month seems expensive but not obviously un-worthwhile. If I make $200,000/year (which is certainly upper class, but not obscenely so), then I would be glad to pay $15,000 per month of life, no matter how many months I would be able to buy.

    Second, how much of my medical insurance premium actually goes to paying for minimally effective cancer treatments? This blog often argues that the marginal benefit of medicine is zero, but I’d guess that this class of treatments (say, those that cost more than $10,000 per month of expected extended life) makes up a rather small fraction of total health care spending. In that case, it could be a waste but a relatively unimportant one.

    • “but I’d guess that this class of treatments (say, those that cost more than $10,000 per month of expected extended life) makes up a rather small fraction of total health care spending. In that case, it could be a waste but a relatively unimportant one.”

      Nope. It makes up the bulk of healthcare costs. 90% of healthcare costs are spent on people in their last year of life. And the majority of those people cannot be saved, their lives are prolonged for months or sometimes even just days.

      • Sorry, that number is way off. More like 20% of Medicare in last year of life.

    • q

      where do you get that 90% number?

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  • Kenny Evitt

    The tiny (though accumulating!) incremental improvements have to come from somewhere. Certainly this shouldn’t be of concern for those with the means and the desire to pay for this care. I AM worried though that something like your argument will be used to prohibit anyone from purchasing an ‘unnecessary’ extra month or two as a matter of fairness (on top of the cost angle). How else are we ever going to get away from the current local maximum?

  • jonathan

    People are afraid to die and families are afraid that if they let family members die – especially older ones – then that is somehow wrong, even evil. If you want to extract an actual cost of religious belief, here it is: keeping people alive for an extra few months of pain because they’re so frightened by the images sold by religion of heaven, hell and purgatory.

    Now if any actual human being had real experience with heaven, hell or purgatory then the fear might have an actual basis, but no human has died, crossed over, passed, etc. and then come back. (References to Jesus aren’t appropriate because in theology the part that came back is divine, not human, and then those are old stories.)

    • mike

      Good point. People who aren’t religious are totally unafraid of dying. Everyone’s atheist in a foxhole, right? Nothing terrifies me more than the thought of going to heaven.

      This has to be the most dimwitted rationalization of anti-religious bigotry that I’ve ever seen.

      • Psychohistorian

        It’s weird, but it actually has some truth behind it. An analysis of health care costs (discussed in Overtreated) finds that the more religious, “red” areas in the middle of the country have a much higher expenditure on this type of questionably useful end-of-life prolonging care as compared to the coastal “blue” areas, which are significantly less religious.

        Of course, saying that it is specifically religion that causes this difference doesn’t follow. But it would not surprise me if the same type of mentality supports both high religiosity and high faith in ineffectual medical intervention.

  • Greg Conen

    Robin, as I read it, he agrees with you. He’s optimistic that reform will change the way that cancer is treated, which he currently considered wasteful and ineffective. His point is confused, but it seems like he’s arguing against the “unrestricted access to care” which spends $15000/month/patient with a 80% failure rate.

  • Bill

    If you structured a joint venture agreement between a seller and buyer, and an event occurred which would require spending by the venture more to the benefit of one of the members, one would draft a split savings clause: if you do not do x, I will split the savings with you.

    It is too bad that insurance does not have a split savings clause with respect to low probability, high cost procedures.

    It would work like this: if you choose not to do x, I will share the savings in not doing the procedure with you.

    Would be interesting to see what happens. Today, people are incented to take a low probability, high cost procedure because they “already paid” for the insurance. What would happen if the savings were shared?

  • Sigivald

    Clinical trials are “wasteful of resources”?

    That’s what he’s talking about being “hopeful” about, after all. And since the entire point of such a trial is to see if something works, it’s not exactly invalid to be “hopeful” about the outcome.

    For that matter, isn’t this analysis ignoring the real effects of patient outlook on outcomes?

    (Personally, I’d rather “waste” resources than give what seems to nearly amount to a medical priestly caste encouragement and incentives to say “shut up and die already, you’re wasting resources!”.)

    Jonathan: I think you’ll find that even atheists don’t want to die, or let their loved ones die – and that a proportion of the religious (I’d speculate roughly equal to the proportion of the irreligious) take an “it’s in God’s hands” sort of view of desperate life-prolonging measures and reject them.

  • Aron

    People optimize to their local conditions, not the global optimum. When a nameless face pays for a named face’s care, you take it. This is obvious, yes?

  • Yet, despite the many recent advances in detection and treatment, of the 50 patients, 40 of them are likely to lose the fight. …

    That sounds worth the try at first blush but we need to know how many would have won the fight without the care.

  • Some times I think that we would better off not knowing that we have cancer or some other diseases.

  • Jeffrey Soreff

    He admits his profession wastes vast resources selling false hope, but we are supposed to let that slide because he is proud to be “hopeful”?

    How, on a per-patient basis, is this a worse bet than cryonics?
    At least the anti-cancer drugs have been through an FDA screening
    for efficacy. Cryonics’s efficacy currently rests wholly on theoretical
    analysis. This isn’t an intrinsically bad position to be in – but it is more
    nearly equivalent to drug leads than to drugs
    which have passed clinical trials. The only reason one can’t make an
    exactly analogous complaint about cryonics wasting vast resources
    selling false hope is that so few of us are signed up for it, so the
    aggregate numbers are smaller.

  • Jeffrey Soreff

    ‘scuse the double posting on the same topic – I hadn’t located the
    quote that I needed earlier.
    From Break Cryonics Down

    Your chance of being usefully revived in 2090 as an em is roughly the product of these ten conditional probability terms. Ten 90% terms gives a total chance of ~1/3. Ten 80% terms gives a total chance of ~10%, except step 4 might be a 50% chance, for a total chance of ~6%, which seems about right to me.

    Contrasting cancer treatment and cryonics, we have a
    20% successful treatment and a 6% effective (estimated) treatment,
    both with costs on the order of $100,000 or so per patient.

    Professor Hanson: You seem to be advocating moving resources
    out of cancer treatment and into cryonics, yet this seems at odds
    with your own estimates of their benefits. Can you explain this?
    I’m comparing these purely in terms of returns on resources
    expended, setting aside any questions of incentives, who pays
    what, etc.

    • Eric Yu

      On average, revived ems have longer to live than surviving cancer patients.

      • Jeffrey Soreff

        Good point. That might wind up being true, and it is a factor in the right direction. On the other hand, if Professor Hanson is right about how fiercely ems will wind up competing and replicating, they/we may impoverish themselves to the point where the electronic equivalent of death by famine is a frequent and lifespan-limiting event.

  • I was diagnosed with Non-Hodgkins Lymphoma on my 38th birthday in 1996. I entered a clinical trial and became the first person in the world with intermediate grade NHL to receive Rituxan as well as the regular chemotherapy. I’m still here, and Rituxan is now the world’s #1 selling cancer drug.

  • sabril

    I don’t know a lot about medicine, but hasn’t the same thing basically happened with AIDS? i.e. treatments that extended life a little bit, and then more, and then more, until treatments got effective enough to extend one’s life for years and years?

    If so, then from a selfish point of view, I’m kinda glad that people are spending money to extend their lives a few months. Maybe by the time I or my loved ones get cancer (and realistically there’s a pretty good chance it will happen), a few months will have turned into 15 or 20 years with most of the misery at the very end.

  • consider

    SRT501 , a GSK resveratrol based drug that will likely never get marketed because it may be too close to regular resveratrol, is being tested on 15 colon/liver cancer patients. 5g a day.

    The resuts are due this month.

    One promising sign is last month’s study that showed regular resvertarol stopped the spread of cancer (liver?) in 70% of mice taking it as opposed to jusr 4% in the control group.

    Multiple Myeloma results for SRT501 will be in late next year. Alzheimes and Prakisons also on dock for trials.

    It looks like GSK is banking on the much more powerful SRT1701 or SRT2401 drugs they hope to market in 2012-2014.