Cancer Compass

[Joe]

This issue contains several interesting articles:

http://www.cancercompass.com/breast-cancer-news.htm


Regards
Joe

[gdpawel]

Although oral tyrosine kinase inhibitors, like Tykerb, offer patients a well-tolerated, conveniently administered alternative to intravenous (IV) therapy, Decisions Resources, one of the world's leading research and advisory firms for pharmaceutical and healthcare issues, found that oncologists are not yet ready to use Tykerb as a replacement for Herceptin. Ninety-one percent of surveyed oncologists stated that intravenous (IV) cancer therapies are more profitable than oral therapies. And fifty-eight percent of oncologists say they would favor IV Herceptin over oral Tykerb because administration of IV drugs remains an important source of income for their practices.

http://www.cancercompass.com/cancer-news/1,13054,00.htm

Selling cancer chemotherapy with concessions creates conflicts of interest for oncologists

The shift in the United States, more than 20 years ago, from the institution-based, inpatient setting to community-based, ambulatory sites for treating the majority of the nation's cancer patients has prompted in large part additional costs to the government and Medicare beneficiaries. The Chemotherapy Concession gave oncologists the financial incentive to select certain forms of chemotherapy over others because they receive higher reimbursement. This was first brought to attention at a Medicare Coverage Advisory Committee meeting in 1999, in Baltimore, Maryland (1).

Typically, doctors give patients prescriptions for drugs that are then filled at pharmacies. But medical oncologists bought chemotherapy drugs themselves, often at prices discounted by drug manufacturers trying to sell more of their products and then administered them intravenously to patients in their offices.

Not only do the medical oncologists have complete logistical, administrative, marketing and financial control of the process, they also control the knowledge of the process. The result is that the medical oncologist selects the product, selects the vendor, decides the markup, conceals details of the transaction to the degree they wish, and delivers the product on their own terms including time, place and modality.

A joint Michigan/Harvard study confirmed that before the new Medicare reform, medical oncologists are more likely to choose cancer drugs that earn them more money (2). A "Patterns of Care" survey showed results that the Medicare reforms have not solved the problem of variations in oncology practice (3).

A patient wants a physician's decision to be based on experience, clinical information, new basic science insights and the like, not on how much money the doctor gets to keep. A patient should know if there are any financial incentives at work in determining what cancer drugs are being prescribed.

I would imagine that some are influenced by the whole state of affairs, possibly without even entirely admitting it. Social science research shows that people can be biased by self-interest without being aware of it. There are so many ways for humans to rationalize their behavior (4).

The U.S. government wasn't reducing payment for cancer care under the new Medicare Modernization Act (MMA) of 2003. They were simply reducing overpayment for chemotherapy drugs, and paying cancer specialists the same as other physicians. The government can't afford to overpay for drugs, in an era where all these new drugs are being introduced, which are fantastically expensive (5).

Although the new Medicare bill tried to curtail the Chemotherapy Concession, private insurers still go along with it. What needs to be done is to remove the profit incentive from the choice of drug treatments. Medical oncologists should be taken out of the retail pharmacy business and force them to be doctors again (6).

1. http://weisenthal.org/hcfa_1.htm http://weisenthal.org/hcfa_2.htm http://weisenthal.org/hcfa_3.htm
2. http://content.healthaffairs.org/cgi...tract/25/2/437
3. http://patternsofcare.com/2005/1/editor.htm
4. http://jama.ama-assn.org/cgi/content/full/290/2/252
5. www.medicare.gov
6. http://ethicsjournal.umc.edu/ojs2/in...e/issue/view/4

[Lani]

Thanks for posting it!

[gdpawel]

Yes!

Over the last seven years, the New York Times has been on this topic like white on rice, as Dr. Brian Klepper, Director of the Center for Practical Health Reform, described it in a recent posting on The Doctor Weighs In blog.

While the Harvard/Michigan study documented what happen before the new Medicare law, a survey by Dr. Neil Love, "Patterns of Care," showed results that the Medicare reforms still were not working. It was still an impossible conflict of interest.

With the lastest New York Times articles exploring the deep financial conflicts in oncology drug prescribing, Dr. Klepper stated, even though Medicare has limited the profits of oncologists who prescribe drugs, Medicare's total cancer care expenditures keep rising because oncologists have found new treatments and procedures to bill for. And the rules guiding Medicare reimbursement for cancer and drug rebates are complex, resulting in patients often receiving more costly drugs.

The government wasn't reducing payment for cancer care under the new Medicare bill. They were simply reducing overpayment for chemotherapy drugs, and paying cancer specialists the same as other physicians. The government can't afford to overpay for drugs, in an era where ALL these new drugs are being introduced, which are fantastically expensive.

Although the new Medicare bill tried to curtail the Chemotherapy Concession, private insurers still go along with it. What needs to be done is to remove the profit incentive from the choice of drug treatments. Medical oncologists should be taken out of the retail pharmacy business and let their expertise as doctors prevail.

In regards to the first link article, aside from the financial incentives working here, there are marked differences between these two drugs.

Cells are the most basic structure of the body. Cells make up tissues, and tissues make up organs, such as the lungs or liver. Each cell is surrounded by a membrane, a thin layer that separates the outside of the cell from the inside.

For a cell to perform necessary functions for the body and respond to its surroundings, it needs to communicate with other cells in the body. Communication occurs through chemical messages in a process called signal transduction. The purpose of these signals is to tell the cell what to do, such as when to grow, divide into two new cells, and die.

Targeted cancer therapies use drugs that block the growth and spread of cancer by interfering with specific molecules involved in carcinogenesis (the process by which normal cells become cancer cells) and tumor growth. By focusing on molecular and cellular changes that are specific to cancer, targeted cancer therapies may be more effective than current treatments and less harmful to normal cells (although some have their own insidious side effects).

Monoclonal antibodies like Herceptin and Erbitux are "large" molecules. These very large molecules don't have a convenient way of getting access to the large majority of cells. Plus, there is multicellular resistance, the drugs affecting only the cells on the outside may not kill these cells if they are in contact with cells on the inside, which are protected from the drug. The cells may pass small molecules back and forth.

Exciting results have come from studies of multitargeted tyrosine kinase inhibitors, "small" molecules that act on multiple receptors in the cancerous cells, like Tykerb and Sutent. Tykerb is one of the first oral agents with the potential to compete directly with the IV drugs which is both a high-volume and high-revenue part of office-based practices. But, is something more elemental going on? Does the drug even enter the cell? Once entered, does it immediately get metabolized or pumped out, or does it accumulate?

Cell culture assays with "functional profiling" are able to measure the response of tumor cells to drug exposure. Following this exposure, it measures both cell metabolism and cell morphology. The effect of drugs on the whole cell, resulting in a cellular response to the drug, measuring the interaction of the entire genome. The variety of metabolic and apoptotic measurements are used to determine if the specific drug was successful at killing the patient's cancer cells.

Results from these assays can show that some clones of tumor cells don't accumulate the drug. These cells won't get killed by it. But you wouldn't pick this up with an assay which only measured the kinases themselves. A "functional profiling" assay measures the net effect of everything which goes on. Are the cells ultimately killed, or aren't they?

Each of these new targeted drugs are not for everybody (just like conventional cancer drugs are not for everybody). Even when the disease is the same type, different patients' tumor respond differently to the same agents. As the saying goes, "don't throw out the baby with the bath water." If a drug works extremely well for only 10% of cancer patients, identify which 10%. If one drug or another is working for "some" people (not average populations), then obviously there are others out there who would also benefit.

The methods of cancer medicine during the last thirty some years are coming to haunt the "one-size-fits-all" establishment. Technologies, developed over the last twenty years by private researchers, hold the key to solving some of the problems confronting a healthcare system that is seeking ways to best allocate available resources while accomplishing the critical task of matching individual patients with the treatments most likely to benefit them.