Monday, 13 November 2017

Measuring the value of anti-cancer drugs

Cristina Roure



Anti-cancer drugs, especially palliative drugs, are toxic, costly and sometimes of little benefit, as a result their value to the patient and society are often questionable. It’s also true that significant improvements in the survival rates are threatened by the difficulty in accessing them, due to their unsustainable cost.


Some scientific societies, such as the American ASCO, but also the European ESMO and other organizations, are developing instruments to quantify the value of cancer drugs. The objective is to provide clear and unbiased information for governmental or syndicate decision making, regarding the access to drugs and to synthesize, in a single metric, the balance between the magnitude and the relevance of the expected clinical benefits and its cost, that is its value. See what it’s all about in this video presentation of the instrument developed by the ESMO: Magnitude of Clinical Benefit Scale (ESMO-MCBS):



JAMA has published an excellent article (1) that compares five of these tools and is accompanied by an editorial (2) that points out its strengths and weaknesses. Reading the article, I thought that it would be very difficult to establish a universal value in the treatment of cancer because, as Michael Porter points out, defining health value implies clearly defining common goals that unite the interests of all parties (3). Some interests, such as accessibility, effectiveness, safety and cost are convergent and all are included in one way or another in these tools. But there are others, which, because they are linked to the individual characteristics and values ​​of each person, or are not common variables in clinical trials, are not included, despite being extremely important.

Consider the case of those elders in the group with the highest incidence of cancer and account for 70% of deaths from this disease (4), but are under-represented in most of the research in oncology, a fact that conditions that all decisions must be taken from the extrapolation of results. Neither do we choose the most interesting variables for the elderly with cancer, such as the benefit they would obtain in terms of personal independence, maintenance of functional capacity, comfort or convenience and burden of treatment, toxicity and efficacy in a situation of multi-morbidity and poly-pharmacy. Oncology clinical trials, on the other hand, focus on overall or progression-free survival, variables thought for the younger population, in which the primary goal is to delay premature cancer death.

Investigations carried out in elderly populations demonstrate that more than 40% of elderly people with cancer notice a deterioration of their capacity to perform instrumental activities of daily living and, although there are tools to evaluate functional dependence or to stratify risk of toxicity of chemotherapy in the elderly, such as the Karnofsky index (4), in clinical oncology studies are absent.

As survival time lengthens and cancer becomes a chronic disease, it’s more necessary to develop new models of geriatric oncology care with a comprehensive view of the person with cancer that contemplates comprehensive geriatric assessment, which integrates, among others, some elements as important as co-morbidity and poly-pharmacy. In the video, Professor Hans Wildiers, an oncologist at the University of Leuven, discusses his experience in implementing comprehensive geriatric assessment in elderly patients with cancer.



We welcome therefore the initiatives of ESMO, ASCO, NCCN, ICER and the abacus drug calculator of the Memorial Sloan Kettering Cancer Centre, because they represent a rigorous effort to rationalize access to new drugs against cancer, but let’s admit that it will be necessary to widen our horizon if we want more person-centred tools that provide a more adequate response to individual decision-making.

As Margaret McCartney says, the pursuit of higher-quality health care necessarily involves a bifocal vision: a relentless campaign to promote new models of evidence synthesis combined with a strong commitment to people-centred care based on respect for diversity and individuality of values ​​and preferences (5).


Bibliography

1. Chandra, A, Shafrin, J, Dhawan, R. Utility of Cancer Value Frameworks for Patients, Payers, and Physicians.JAMA. 2016;315(19):2069-2070.
2. Basch, E. Toward a Patient-Centered Value Framework in Oncology.JAMA 315.19 (2016): 2073-2074.
3. Porter M. What Is Value in Health Care?. N Engl J Med 2010; 363:2477-2481.
4. Magnuson A, Dale W, Mohile S. Models of Care in Geriatric Oncology. Curr Geriatr Rep. 2014 Sep; 3(3): 182–189.
5. Mc Cartney M, Treadwell J, Maskrey N, Lehman R. Making evidence based medicine work for individual patients. BMJ 2016; 353: i2452


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