As a clinician, I want these drugs and others like them to be available for my patients. As one who worries how we will make them available and minimize disparities, I have a major problem—and that is that these drugs cost too much.
—Leonard Saltz, MD
If new immunotherapy combinations were administered to the half a million Americans dying of cancer each year, the nation’s price tag for treating them—for just 1 year—could top $174 billion, according to projections by Leonard Saltz, MD, Chief of Gastrointestinal Oncology and Chair of the Pharmacy and Therapeutics Committee at Memorial Sloan Kettering Cancer Center. Dr. Saltz offered his perspective on value in cancer care at the Plenary Session of the 2015 ASCO Annual Meeting.
“We must acknowledge that there must be some upper limit to how much we can, as a society, afford to pay to treat each patient with cancer,” Dr. Saltz said.
Many of the attention-grabbing studies presented at the 2015 ASCO Annual Meeting pertained to immunotherapies, which are being evaluated in a growing number of tumor types. Dr. Saltz pointed out how these exciting new drugs are clearly accentuating the cost-of-care crisis.
As one example, Dr. Saltz focused on the CheckMate 067 trial of nivolumab (Opdivo) plus ipilimumab (Yervoy) in advanced melanoma, presented at the Plenary Session by Jedd Wolchok, MD, which yielded a median progression-free survival rate of 11.4 months, compared with 6.9 months for nivolumab alone and 2.9 months for ipilimumab alone.1
“A median progression-free survival of 11.4 months is truly remarkable, for a disease that 5 years ago was thought virtually untreatable,” Dr. Saltz said. “As a clinician, I want these drugs and others like them to be available for my patients. As one who worries how we will make them available and minimize disparities, I have a major problem—and that is that these drugs cost too much.”
He cited the current per-mg costs to be $28.78 for nivolumab and $157.46 for ipilimumab; the other anti–PD-1 (programmed cell death protein 1) agent, pembrolizumab (Keytruda), costs $51.79/mg. “To put that into perspective, that’s approximately 4,000 times the cost of gold,” Dr. Saltz said.
In the clinic, therefore, the cost of treating an “average-sized” (80 kg) American patient with the combination of nivolumab plus ipilimumab for advanced melanoma would exceed $295,500. Treatment with nivolumab alone would be $103,220, and ipilimumab alone—to achieve a median remission of less than 3 months—would cost $158,252.
Rounding the cost of treatment up to about $300,000 for the individual patient with a 20% copay, the patient’s responsibility would be approximately $60,000, Dr. Saltz pointed out.
Taking this nationally—with 1.6 million cancer cases expected this year and 589,430 deaths—giving $295,000 worth of drugs to each patient with metastatic disease would cost $173,881,850,000, Dr. Saltz projected. “That’s $174 billion in 1 year for drugs treating patients with metastatic disease—no adjuvant therapy—for 1 year only,” he emphasized.
Dr. Saltz also questioned the need to use pembrolizumab at a dose of 10 mg/kg—far higher than its U.S. Food and Drug Administration (FDA)-indicated dose of 2 mg/kg every 2 weeks. The monthly cost for the higher-dose regimen is $83,500, he calculated, and this dose (10 mg/kg every 2 weeks) was evaluated in at least five studies presented at the 2015 ASCO Annual Meeting, he noted.
Single-agent treatment, at this dose, for a 75-kg patient who needs 26 doses per year, generates a per-patient price tag of $1,009,944, Dr. Saltz estimated. “This is unsustainable,” he said.
Solving the Problem
Potential solutions to escalating drug costs have been bandied about for years now, and Dr. Saltz reiterated them. Two important changes are to allow the FDA, the “gatekeeper,” to consider price in the approval process and to allow the Centers for Medicare and Medicaid Services, as the major purchaser of drugs, to negotiate prices with industry, he said.
Dr. Saltz emphasized that there must be an upper limit to how much society will pay to treat cancer; that discussions of value and cost must be encouraged within industry, government, patients, and “amongst ourselves”; and that alternative payment strategies that do not incentivize on the cost of drugs must be adopted. “There’s a tipping point that we have to be willing to search for,” he said.
Meanwhile, he urged ASCO members to discuss patients’ concerns regarding cost and finances and understand and explore the limitations of their insurance coverage. If the current trend continues, he noted, by 2028, a full 100% of household income will be required to cover the cost of insurance premiums and out-of-pocket costs, he said.
“We can embrace our responsibility to deliver high-value, cost-effective care. That means choosing wisely, and choosing not to deliver lower-value, cost-ineffective care,” he said. ■
Disclosure: Dr. Saltz reported no potential conflicts of interest. Dr. Wolchok is a paid consultant and his institution receives research funding from Bristol-Myers Squibb.
1. Wolchok JD, Chiarion-Sileni V, Gonzalez R, et al: Efficacy and safety results from a phase III trial of nivolumab alone or combined with ipilimumab versus ipilimumab alone in treatment-naive patients with advanced melanoma. 2015 ASCO Annual Meeting. Abstract LBA1. Presented May 31, 2015.