Hey, guess what? One of these things is not like the other - can you determine which anti-cancer treatment does not belong in this list?
JM-216 (satraplatin): an oral platinum analogue active against hormone-refractory prostate cancer
JM-/AMD-473 (picoplatin): an intravenous platinum analogue showing promising activity against small cell lung cancer
Diaminocyclohexane [DACH]-based AP-5346 and aroplatin/liposomal cis-bis-neodecanoato-trans-(R,R)-1,2-diaminocyclohexane platinum (II) [L-NDDP]: innovative new platinum-delivery systems
Cis-[(1 R,2 R)-1,2-cyclohexanediamine-N,N] [oxalato(2-)- O,O] platinum (oxaliplatin): another platinum-based chemotherapy drug active against colorectal cancer
Bevacizumab: a humanized monoclonal antibody that attaches to vascular endothelial growth factor
(Nota bene, this is a trick question)
The answer: oxaliplatin does not belong, at least not in Nova Scotia, Canada, because it is the only drug approved for payment by the Ministry there. The top three items are all experimental platinums (or platinum delivery vehicles), not licensed for use, and bevacizumab (Avastin®) just got cashiered by the province's panjandrums. Was this a King Solomon-like decision, or one destined for ridicule by future graduate students?
"N[ova].S[cotia]. rejects funding for cancer drug Avastin"
The Nova Scotia government could be held responsible for the premature deaths of some cancer patients because of its decision to reject funding for an expensive cancer drug, a colorectal cancer patient said yesterday. In a decision the province's Health Minister called "one of the most difficult" he's had to make, Avastin - a drug used to prevent the spread of colorectal cancer to other organs - will not be among the new cancer drugs to be publicly funded as of Aug. 1.
"The effect of this decision is that people will die before they ought to," said Jim Connors, 51, who has paid for his own treatment of Avastin.
Now there are many points to be made regarding this story from Canada, such as bevacizumab (Avastin) not only prolongs life in colon cancer but also in non-small cell lung cancer, breast cancer and renal cell carcinoma, but I limit my scope today to the decision to withhold payment for colon cancer. The province hired a 23-person committee (a fine example of bureaucratic dithering - even our Supreme Court only needs nine warm bodies to render their little judgments) to decide which horribly expensive new anti-cancer agents ought to be covered by the guv'mint. The committee recommended the approval of oxaliplatin for the adjuvant treatment of early stage, resected colon cancer but rejected paying for bevacizumab in the treatment of metastatic colon cancer.
Committee members looked at the economics and new evidence on Avastin, and concluded it did not offer the same potential as Oxaliplatin in early stages of cancer.
"Oxaliplatin ... post surgery, it prevents any micro or very small cells from being spread throughout the body, so it is in fact a cure," said Brenda Payne, a committee member and executive director of acute and tertiary care for the department of health. "Avastin is used at advanced stages of the disease, so it does not have a curative component to it."
Amazing! Does Ms. Payne understand the difference between conducting a clinical trial looking to see if a new drug prolongs the survival of incurable cancer patients and running an adjuvant trial using the same drug to observe any increase the surgical cure rate? The contrast should be obvious, even to the 23-person Nova Scotian committee of repute, which makes her comments illogical. What if we give oxaliplatin to patients with advanced, incurable metastatic colon cancer and it prolongs their survival (compared to the control), but doesn't cure them? Should we then recommend that it be verboten, even if it increases the cure rate in early stage disease? Would we not allow oxaliplatin to be on the magic list of covered agents, at least as part of adjuvant therapy?
Okay, we all agree. Now what if one gives bevacizumab to a colon cancer patient in the adjuvant setting, and it (to quote Ms. Payne) "prevents any micro or very small cells from being spread throughout the body, so it is in fact a cure," would bevacizumab then be worthy of being paid for by the Ministry of Health (or would the Ministry of Truth have a problem with that)?
My prediction is that if you are a big fan of rationing health care dollars you just might want to hold off on shorting Genentech. There are two large clinical trials in progress now - NSABP C-08 and the AVANT study - which randomize patients with resected colon cancer to either adjuvant chemotherapy, or adjuvant chemotherapy with - you guessed it - the dreaded bevacizumab. Ms. Brenda Payne's concerns about giving desperately ill cancer patients therapy that prolongs their survival but doesn't cure them, therefore, will soon be allayed. The addition of bevacizumab will either increase the cure rate, decrease the cure rate, or have no effect on the cure rate. If the results are favorable, then follows the pain of deciding whether or not one's citizens deserve such happiness.
We eagerly await the results of these two trials. In the meantime, let us remind ourselves of the benefits trying new agents against metastatic colorectal cancer, as costly as they may be. [from Meyerhardt and Mayer, New England Journal of Medicine, Volume 352:476-487.]
I honestly don't know how any living human being could ever be proud of earning the right to have the following epitaph carved on their headstone:
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What I don't understand is why the rest of the world doesn't have the ability to get their acts together and replace all their lights with leds. It is much, much, much better on the
is why the rest of the world doesn't have the ability to get their acts together and replace all their lights with leds. It is much, much, much better on the
It is much, much, much better on the
Thanks...
thanks
cure is irrelevant. however, cure is (you hope) effectively an extension to normal life expectancy, which for the fifty or sixty year olds with cancer, immense in absolute terms - an additional ten or fifteen years.
in australia, for example, oxaliplatin is only funded for stage 3 CRCA, because the evidence of cost-effectiveness over 5-FU in stage 2 isn't really there.
Yes, given that the world has infinite resources, it's only because of government that things get rationed.
What is the cost in QALY for Avastin. I think that Genetech is more to blame for their pricing than the government of Nova Scotia for their management of resources, but I'm a pinko, commie liberal who believes in universal access. BTW, contrary to popular belief, if you have the money (or insurance that covers it - unlikely), Avastin is still available in Nova Scotia.
I wouldn't want to be the one making these decisions.
Some of these drugs are hugely expensive. Are they worth as much as they cost? What's the trade off for funding them all, how much added to the budget each year? What's the expected benefit? Would they be worth it if they cost just a little bit less? I don't know. I don't know how I'd even go about making the decision. I could get all of the data, understand it, and still not really know what's the best decision. How do you make the call when it's not clear-cut?
After reading some of the rather cold hearted comments here (made by others and not the cheerful oncologist), it is easy to say that a medication should not be provided based purely on economics. Morally, however two wrongs do not make a right. Corruptions whether in government, the pharmaceutical industry, or in other practices has always existed. To ensure that everyone has access to the medications they need is essential for a productive society. Not only does Avastin prolong life even by what some claim is only a few months, what Avastin provides is a chance for families to create more memories with their loved one�s. Tell the young children who are losing their parents that their parent�s lives are not worth the price tags associated with the cost of Avastin or other essential treatments. One most not ever place a price on a human life for life is not only precious, but worth far more than can ever be quantified numerically or otherwise.
Lastly, if one of the poorest provinces in Canada, Newfoundland can find the means to cover Avastin than, so can the rest. As a Nova Scotian it sickens me that the NS government saw fit to waste millions on trying to bring the Commonwealth Games to NS, and often have provided a hand out to large companies that regularly leave our province and our people behind without work. However, when it comes to the health and well being of our own they are left to suffer. These individuals are not even being provided with a hand in paying a percentage of what they can afford for Avastin - whist the government covers the reminder, as this option, and others have not been provided to the people who are most in need of this treatment.
thanks you
Yes, given that the world has infinite resources, it's only because of government that things get rationed.