It's really about living and not waiting to die.
──Gailanne Reeh, 乳癌病人
美國的癌症藥物，目前是排名第二的錢坑藥品，2007年美國人花了將近180億在上頭。（我怎麼一點都不意外最大的錢坑是抗血脂藥呢？）
可是，有不少的抗癌藥，效果並不如藥商所宣稱的那麼好，但價格卻非常昂貴，像是宣稱對早期乳癌、肺癌和大腸癌有療效的Avastin，不但療效比預期的差，甚至有可能致死的副作用，一年份的藥物就要10萬美金，沒有保險的窮人根本就負擔不起。
這麼一來，出保費的健康人就會問：
爲什麼我繳的錢得用來買這種可能沒效卻又很貴的藥？
癌症的病人也問：
那如果在我身上有用呢？
夾在中間的醫生就很左右為難啊！夜深人靜時他會想，開這些藥只是造成要保人的負擔而已，可是一但面對病人，他總不能說：「這藥太貴了，對同樣出保費的人不公平，我不能開給你。」
雖然說自由市場的價格，由供給與需求決定。但是，研發癌症藥物的成本如此之高，真的就能靠因為藥品太貴而不得不降價，以提高需求來打平嗎？還是，更糟糕的結果是，藥廠只求有一兩種像威而剛一樣的搖錢樹，而不再砸錢研發藥物呢？難道說，到頭來，醫療服務就只會是有錢人才能享受的福利嗎？
Seattle Times
Cancer drugs' costs pose a dilemma
By GINA KOLATA and ANDREW POLLACK
The New York Times
It took only an instant for Gailanne Reeh, 58, to go from the picture of health to death's door. By chance, her doctor noticed a lump under her arm during a routine exam. It turned out to be advanced breast cancer.
Soon she was having tests to reveal the extent of the cancer and hearing the grim results.
The surgeon, she recalled, "looked at me and said: 'This is not a conversation I like to have. But I can't do anything for you. ... All we can do is manage your cancer.' " On scans to detect tumors, the doctor told Reeh, "you light up like a Christmas tree."
And so, like many others in that situation, Reeh, the owner of a staffing agency in
Looked at one way, Avastin, made by Genentech, is a wonder drug. Approved for patients with advanced lung, colon or breast cancer, it cuts off tumors' blood supply. And despite its price, which can reach $100,000 a year, Avastin has become one of the most popular cancer drugs in the world, with sales last year of about $3.5 billion, $2.3 billion of that in the
But there is another side to Avastin. Studies show the drug prolongs life by only a few months, if that. Some newer studies suggest the drug might be less effective against cancer than the Food and Drug Administration had understood when the agency approved its uses.
While many patients and their doctors said the drug can improve the quality of life — such as a sense of well-being and an ability to carry out daily tasks without exhaustion or pain — such effects can be hard to document. Meanwhile, many patients with other cancers are taking the drug, even where there is no compelling evidence it can help.
Avastin also has serious, if infrequent, side effects, some of which can be lethal. And because it is almost always used with standard chemotherapy — it did not work as well when researchers tried it alone — patients on Avastin do not escape chemotherapy's side effects.
"I still use Avastin routinely, but it's sobering," Dr. Leonard Saltz, a colon-cancer specialist at
Debatable benefits
If Avastin were inexpensive or if it cured cancer or even held it at bay, as the drug Gleevec does for blood cancer, few might care. But like about six new biotechnology drugs with a similar combination — alluring promise, high price and debatable benefits — Avastin raises troubling questions:
What does it mean to say an expensive drug works? Is slowing the growth of tumors enough if life is not significantly prolonged or improved? How much evidence must there be before billions of dollars are spent on a drug? Who decides? When, if ever, should cost come into the equation?
For a patient such as Reeh, cost is not the main concern. If her insurer did not pay, she said, she would find a way to raise the money.
But some in the pharmaceutical industry worry such prices will raise concerns about whether the drugs are worth it, leading to a backlash such as price controls or restrictions on use.
Some patient advocates are also troubled by expensive treatments such as Avastin being used routinely on what they see as little more than a hope and an expensive prayer.
"It's absolutely critical that we start having a public discussion," said Barbara Brenner, executive director of Breast Cancer Action, an advocacy group. "I think of Avastin as a model that is showing us where the problem is."
About 100,000 Americans take Avastin, according to Genentech's data. The drug is being tested in up to 450 clinical trials for about 30 types of cancer. And Genentech, its partner Roche and the National Cancer Institute are starting studies that will include more than 26,000 people with lung, colon or breast cancer at earlier stages of the disease than were studied initially.
If Avastin is approved for those earlier-stage patient groups, it could have a major impact in delaying the return of their cancer, but hundreds of thousands of additional people could end up taking it, possibly for years. And that, insurers and patient advocates said, could impose a financial burden.
Enrolled in trial
As for Reeh, her oncologist, Dr. Eric Winer of Dana-Farber Cancer Institute in
The study closed after six months, but Reeh continued with her drug regimen, and her insurer is paying. After six months of treatment, her tumors were stable or smaller. She felt like her former self again.
"I'm really, really excited," she said.
Was it the Avastin?
Winer said he did not know, since Taxol can also shrink tumors. It is impossible to draw conclusions from individual patients, he said. Still, he said, "I think it is quite likely that the combination of Taxol and Avastin improved her odds of having a better quality of life."
Winer said that when he is not sitting in front of a patient, he thinks about whether drugs such as Avastin are worth it to society. But when facing a patient, who, based on clinical trial results, might benefit — even if only a little — from Avastin along with chemotherapy, he has to think about his patient's needs.
"I can't say, 'Let's not use Avastin; it's a very expensive drug and I am worried about the cost to society,' " he said.
And so, Winer said, the answer you get when you ask whether drugs such as Avastin are worth it, it very much depends on whom you ask.
"A person who hasn't been affected by cancer will say, 'Gee, why should we pay for an expensive treatment that doesn't extend life when we have other needs?' " Winer said.
A person such as Reeh will have a different response. She does not want to give up Avastin. Last month, she reluctantly stopped taking her drugs for a while because Taxol was injuring the nerves in her feet. But this month she hopes to resume taking both drugs, or at least Avastin.
She said she knows her cancer may very well kill her eventually. But what is it worth to feel better again?
"It's really about living and not waiting to die," she said.
Cancer-drug spending
Cancer drugs constitute the second-biggest category of drugs in the
Source: IMS Health
Copyright © 2008 The Seattle Times Company
