The sticker shock arrived with the first CAR T-cell therapies. OncLive reported in May 2018 that up-front prices were approaching $500,000 for a single treatment. Two products, Novartis’ Kymriah and Gilead Sciences’ Yescarta, were priced between $373,000 and $475,000 for each patient, with the exact figure set by cancer type, according to BioSpace.
Checkpoint inhibitors cost far less per course, but they are given to far more people. OncLive put the bill for these and similar immunotherapy drugs at more than $100,000 per patient each year.
Why the bills run so high
Every CAR-T dose is built for one person. Their T-cells are removed, engineered to recognize a protein on the cancer, and infused back. The lab work takes more than three weeks, and BioSpace put manufacturing and processing at about $60,000 per patient. Drugmakers add that bringing a medicine to market costs $1 billion or more, and they say many patients receive significant discounts.
The wider trend was already steep. Between 2012 and 2016 the global cost of cancer therapeutics and supportive care drugs climbed from $91 billion to $113 billion, and the United States accounted for 46 percent of it. A year of cancer drugs averaged under $10,000 in the year 2000; by 2015 it topped $120,000. Meanwhile a typical four-person family saw average income slip 8 percent, to $52,000.
Is the price worth it?
Economists have mostly said yes, with caveats. For tisagenlecleucel in B-cell precursor acute lymphoblastic leukemia, an analysis found the cost stayed below $50,000 per quality-adjusted life year (QALY) even after a $100,000 markup. That is well under the $150,000 threshold commonly used, over a seven-year horizon. Mark Faries of the John Wayne Cancer Institute told Healthline that if a therapy is curative, its total cost might come in below repeated courses of cheaper but less effective treatment such as chemotherapy.
Not everyone is comfortable with the evidence. Prasad, an assistant professor at Oregon Health and Science University pointed out that the pivotal ELIANA trial of tisagenlecleucel had published updated results in February 2018 that included nothing beyond April 2017. In an uncontrolled study, he said, there is no reason not to update, and later data could revise cost-effectiveness dramatically.
Budget impact is a separate worry. Because lung and breast cancers are so common, the Institute for Clinical and Economic Review estimated that spending on nivolumab for non-small cell lung cancer alone could pass its $904 million threshold in a year.
Who sets the price?
Many countries run formal cost-benefit reviews before paying for expensive drugs. The United States does not. In March 2018 the President’s Cancer Panel issued a report on the financial toxicity of cancer care and called for a widely accepted value framework for pricing.
Britain’s approach is the contrast. In September 2017 its cost watchdog NICE recommended Bristol-Myers Squibb’s Opdivo for some lung cancer patients, but only after a discounted price had been agreed. Legislation is a harder route in America. Ezekiel Emanuel of the University of Pennsylvania wrote in the Wall Street Journal that more than 175 million Americans hold private insurance that Medicare price negotiations would not touch.
Sources
- Why Does Immunotherapy Cost So Much? (BioSpace)
- Debating Value Versus Cost for Immunotherapy (OncLive)
