Once again, as I finish the latest tabulation of medical bills received so far, I am struck by the astronomical cost of the three drugs that make up my TCH regimen: T for Taxotere, C for Carboplatin and H for Herceptin.
Globally, drugs like these involve mega-bucks, despite the fact that many countries impose strict price controls on what companies charge for oncology drugs. In 2006, global oncology drug sales hit $30 billion, according to IMS Health, a consulting firm. By 2009, sales exceeded $50 billion, according to Reportlinker, a market research company.
The United States is much more lenient about pricing and, not surprisingly, prices are generally highest here.
In my case, no single thing costs more than the chemotherapy drugs, not surgery, not radiation, not even high-tech scans. The pre-infusion appointment with the nurse practitioner costs only a couple hundred bucks. The blood workup is about $800. The ministrations of the infusion center nurses runs about $1,200. But the drugs, well, the drugs for Infusion 5 cost $27,236.
Taxotere is a “taxane,” a relative of Taxol, a drug that grew out of 1970s work discovering that extracts of the rare Pacific Yew tree could interfere with cell division. These drugs mess with the “microtubules” that are crucial to making one cell into two cells. After a few days of microtubule disturbance, fast-growing cells hit the auto-destruct sequence. Taxotere, which is used to treat breast, ovarian and non-small-cell lung cancers seems to have three main benefits over Taxol:
1) It is semi-synthetic, easing the pressure to harvest rare trees to make drugs, it can readily be extracted from the common European yew tree.
2) It’s less expensive than Taxol. In the 1990s, Taxol was so pricey that it was not often prescribed in Britain’s national health service. Many women opted to self-pay instead.
3) It seems to cause less severe “neuropathy” (i.e. aches, tingling in extremities etc.) than Taxol.
One dose for me (doses vary according to body mass, and I’m going to go into more detail than that!) costs $8,208.00. The patent on Taxotere ran out in 2010, but the price for infusion 6 remained the same. But with the patent just expired, I guess I’m not surprised that it still costs a lot.
Then there’s Herceptin, brought to you by Genentech, the darling of the biotech world. Herceptin is a “monoclonal antibody.” It’s made up of clones of a single parent immune cell. These have been programmed to target cancer cells that produce too much of a growth hormone called Her2/neu. Having cancer that’s Her-2 positive used to signal a pretty grim prognosis. Today, being “Her2 positive” is seen as a plus because Herceptin is so effective against these sort of cancer cells.
Obviously, all that bioengineering took some time and trouble and the patent hasn’t yet expired. So again, it’s not that surprising that Herceptin would be pricey. One dose for me costs $9,506.00
It’s Carboplatin that puzzles. Carboplatin is a compound of platinum, the “second generation” drug that seems to cause less nerve problems than its predecessor cisplatin.
The patent expired in 2002. In 2006, a report by Cancer e Search Inc. found that Carboplatin prices had fallen approximately 20 percent due to the introduction of generic forms of the drug. Yet the cost is still $16 more than Herceptin: $9,522 for my sixth and last infusion. Herceptin and Taxotere are global market leaders. Carboplatin, while still a major anti-cancer drug, may no longer be such a blockbuster.
So why the high price? I peck away at this question for several weeks.
Is it just that platinum, a precious metal, is very, very expensive?
As of March 24, 2011, the per-kilo price for platinum is $56,328. I’m not sure exactly how much of carboplatin is actually platinum, but let’s say that it’s ALL platinum for the sake of argument. My dose is .9 grams, round that up to 1 gram to make the math easy, and the cost of the platinum is just $56.32. This is, obviously, a lot less than $9,522. So why the extra $8,900 or so?
Could it be royalties?
Cisplatin and carboplatin were discovered by accident in the 1960s when Michigan State University researchers used platinum electrodes for some experiments. The researchers though that the electrodes would be “inert,” i.e. that they would not react chemically. But when an electric current was applied, it reacted with the growth medium to form filaments that interfered with cell division. The researchers reasoned that this might be useful in cancer treatment, and the drugs were eventually patented in the 1970s. Bristol Myers Squib licensed the research from Michigan State and made a pretty penny doing so. But these patents have run out. And besides, the royalties due to MSU were never more than a several million a year.
Could it be that carboplatin is just really, really difficult to make?
Carboplatin is a crystalline powder that becomes active (able to mess with the DNA of cancer cells) when it’s dissolved in water. The patent filing for the drug explains various possible ways to synthesize the drug. I am not a trained chemist—far from it—but these seem to involve dissolving the drug components in water or acid. Then the solution is heated for an hour or so, until it evaporates to dryness. After that, the residue is collected, washed with ether and dried again. Again, I am no expert in the art of chemistry, but that doesn’t SOUND so difficult.
Maybe it depends on where the Carboplatin is purchased?
So I ask Dr. Rugo, my oncologist, about the high price of Carboplatin. “I’m not sure,” she says. “I could ask the pharmacy for you. It may be that they just didn’t buy the generic for your infusion.” Later, I go home and log on to pharmacychecker.com, a Canadian generic drug site. If I bought my Carboplatin over the Internet, my dose would cost $20,000! Using that for comparison, UCSF is getting a bargain at only $9,522.
Then during my last chemo infusion, I ask an intern about my Carboplatin research. She says she’s not sure about that particular drug, but someone did tell her that the Infusion Center is what makes the UCSF Mt. Zion Hospital profitable. “Everything else—the clinics, the imaging and all that—operate in the red,” she says. “The infusion center brings the whole hospital into the black.” I have mentioned this idea to several clinicians in the last month and they’ve all nodded knowingly.
I mention my research to my brother, who has had a run-in with localized liver cancer and a scare when docs saw a spot on his lung that turned out to be nothing. “You know what I think?” he says. “I think that those numbers aren’t really real to anyone. They’re just numbers on a spreadsheet. The hospital bills the insurance company, or Medicare, which debits some account, somewhere. The cost doesn’t enter into the world in a way that makes people deal with it.”
I think he’s onto something. You can bet I would have noticed if I’d had to count out 95 hundred-dollar bills before they hooked up the IV bag with my first Carboplatin dose. Or perhaps if Blue Cross had to pay my bill in cash, they’d negotiate a better deal. Of course, that’s never going to happen.
The incidence of cancer is expected to more than double in the coming decades, according to the World Health Organization, so pharmaceutical companies are falling all over each other trying to bring more anti-cancer drugs to market. I guess I’m glad that anti-cancer drugs are so profitable. Hopefully, I will live to see my grandchildren because they can make a lot of money curing tumors like the one that appeared in my left breast last summer.
But does it have to be so obscenely profitable? Don’t lawmakers and health insurance executives have heart palpitations when they look at the cost-per-dose of oncology medicines? Apparently not.
After almost a month of pecking away at this question, I don’t have an answer. I suspect, however, that my husband’s quip at the beginning of this little project may be closest to the truth.
“Why does big pharma charge so much for chemo drugs?” he said, chuckling. “Because they can.”