Devika Das, MBBS, reviews the evidence presented at ASCO20 Virtual, the annual meeting of the American Society of Clinical Oncology, and concludes that some deep reforms are needed in oncology care to improve access.
The idea that “resources affect who lives and dies” is cringeworthy, but this is a very real phenomenon that reveals itself in multiple ways throughout the US cancer treatment system, said Devika Das, MBBS, who presented at ASCO20 Virtual, the annual meeting of the American Society of Clinical Oncology (ASCO).
Biosimilars are part of the solution for a broken system in the United States, one that wallops health care consumers with higher costs each year while offering them uncoordinated, poorly navigated care that could be tuned up for much better results, said Das, clinical assistant professor of hematology and oncology at the University of Alabama at Birmingham and the Birmingham Veterans Affairs Medical Center.
“A truly high-value drug is the one that costs the least and has the most benefit for our patients,” she said in a discussion of findings presented at this year’s ASCO meeting.
The pharmacy shelves and cooling cabinets are stocked with a variety of medicines, some of which fail to meet this standard, Das said. “What we need is more research focusing on value-based pricing, rigorous post-approval follow-up for efficacy and toxicity, and use of real world evidence in the creation of standardized treatment pathways.”
Cancer Mortality and Access
A brief look at cancer mortality statistics tells a lot of the story, she said. Das peered through the window of the Affordable Care Act (ACA) to show how death rates from cancer dropped dramatically as health coverage became available to 20 million more Americans starting in 2010. Mortality dropped further in states that expanded access to Medicaid under the ACA.
In states that did not expand Medicare, cancer mortality per 100,000 individuals dropped from 69.5 to 52.3 from 1999 to 2017, but in those that did expand, the rate dropped from 65.1 to 46.3 per 100,000. There were more pronounced declines for whites and blacks than for Hispanics, which bears investigation, Das said.
However, these numbers paint a clear picture of how expanded access to health care can make a huge difference in survival in just the oncology sector, she said.
Das swiveled the lens to view the access issue from another angle, that of the rising cost of drugs, particularly innovative specialty medications that, when launched, tend to command increasingly eye-popping prices.
It’s no secret that launch prices of drugs in the United States are rising, but a study presented at ASCO put a ruler next to these increases to measure drug costs in the United States versus those in European countries. Overall launch prices from 2009 to 2019 increased 212% in the United States, 58% in England, 49% in Germany, and 54% in Switzerland.
The 3 European countries have been far more successful than the United States in bringing down the cost of drugs post launch. Investigators included 42 drugs in this study and found that post-launch prices of 36 (86%), 40 (95%), and 38 (90%) drugs decreased over time in Germany, Switzerland, and England respectively. In the US, far fewer drugs decreased in cost after launch, investigators said.
The authors of this study, which also was presented at ASCO20 Virtual, remarked in their abstract that the United States could succeed in trimming the costs of cancer drugs if it adopted the same methods used to negotiate drug prices in Europe.
“Launch prices for cancer drugs are far higher in the United States than in Germany, Switzerland, or England. These price disparities continue to increase substantially after market entry, since cancer drug prices, in general, decrease over time in Europe and increase in the United States,” the authors wrote.
The Right Agents Must Be Prescribed
Targeted therapies, such as bevacizumab, which is available in biosimilar form, can be used to treat non—small cell lung cancer, but some patients don’t get to the point where a decision can be made to use one of these agents, Das noted in her review of data presented at the conference.
A study of patients in the Veterans Health Affairs’ National Precision Oncology Program demonstrated that 117 patients with non—small cell lung cancer in a larger population that underwent next generation gene panel testing turned out to have actionable “smoking gun” gene variations. However, 49 (41.2%) “were not prescribed available targeted agents.”
This problem is not limited to government health programs. This scenario may sound familiar to many practicing oncologists in the United States, Das said. “Often we send out tests, they come back in 7 to 10 days, they are faxed to our offices, and then uploaded to our electronic medical record, with no alerts sent to providers.”
This disjointed system does not serve the patient’s best interests and makes access to appropriate care a more elusive goal. What’s needed, she said, is a complete systems redesign. “To truly fix health care, we need a 2-pronged approach of policy reform and health care delivery reform together. It will make innovation equitable and accessible to all.”