The Skewed Values of Drug Prices

The eye-popping pricing strategies for two pharmaceuticals have been big news lately. First, the cost of a weekly progesterone injection, designed to prevent premature births in at-risk pregnant women, jumped from about $20 per shot to $1,500 per shot.

What happened? The active ingredient of the shot had been compounded by pharmacies as needed by physician request to prevent premature births in the past, while the FDA quietly looked the other way. But in February, the FDA officially approved KV Pharmaceutical's version of the shot, Makena, and KV Pharmaceutical decided to raise the price - a lot.

It was a stunning move for a product whose development was partially funded by taxpayers through the National Institutes of Health, and whose approval had been fast-tracked and supported by the FDA's Orphan Drug Act, according to a recent FDA statement. In response to public outcry, KV Pharmaceutical later dropped the price to $690 per dose. 

Then, on March 30, Medicare announced (in a preliminary decision still in the comment phase) that it would cover the $93,000 price tag of Dendron Corporation's prostate cancer vaccine Provenge, which extends life for a few months in cancer patients.

Dendron's website currently runs an ad for Provenge called "Jonathan's story." In the ad, the patient says "fighting my cancer could mean meeting my new granddaughter, who is due in a few months."  But ironically, current health care policy pits infant health against health care for the elderly.

Is it wise to pay for medication that could extend a long life a few months longer, while allowing companies to create financial barriers to accessing medicine that could help an infant get a healthy start on life? It isn't if you look at health care as a tool to extend healthy years of life, a view that is currently shifting kidney allocation rules, as I've blogged before. In an opinion piece in the Washington Post this weekend, a prostate cancer survivor points out a similar resource allocation problem with Provenge:

One thing I can assure you is that I would never ask Medicare to pay $93,000 for a treatment to extend my life four months. However, I would ask Medicare officials this: if Provenge is prescribed to me as a possible treatment and I turn it down, could I put the savings into a college fund trust account for my grandchildren? I feel the country would benefit much more from educating three of its citizens than from keeping me around another four months. I have a hunch Medicare's answer would be no. 

We need to ask what society owes to two vulnerable populations - pregnant young women at risk of preterm delivery, and terminally ill older men. Rather than pittting ACOG against the AARP, we should step back and ask what is a reasonable amount of funds to invest in protecting each of these populations. And what is a fair and ethical price to charge for the medications they need?

Would You Want to Know?

If you could find out what diseases you might have in the future, would you want to know? Researchers at Tufts Medical Center in Boston recently asked people this very question.

The survey they conducted, and whose results were published in a recent issue of Health Economics, asked 1,463 participants whether they would take a blood test to learn whether they would develop Alzheimer's disease, arthritis, breast cancer, or prostate cancer in the future. They were also asked how much they would pay for that test ("Willingness-to-pay for predictive tests with no immediate treatment implications: a survey of US residents").

Most participants in this hypothetical scenario said that they would want to know whether disease would strike in the future, particularly prostate or breast cancer. They would also be willing to pay up to several hundred dollars to find out.

About a quarter of participants, however, said they would not want to take the blood test. Researchers found that those who were healthier, older, well-educated, and female were more likely to decline the test. "Major concerns expressed included the cost of the test, living with the knowledge of one's disease risk, and the lack of preventive measures [to stop the disease from occurring]," a press release on the survey explained.

Is it better to know, or not to know, what illness you might develop in the future? For some people, it's easier not to know, to not add another worry to their life. I was surprised to learn that most people do want to know what diseases they might develop, though, even if they can't do anything to stop them.

Knowledge is power, and the participants that would want to take the blood test said that they would make the most of their time if they knew they were slated for a life-altering illness in the future, spending more time with family and traveling, for example.

A serious illness brings its own clarity to a person, stripping away trivial concerns, and refocusing their energies on the people and things they care about most. I wish more people had this clarity - without any traumatic trigger such as illness.

Gender and Cancer Vaccines

A number of cancer vaccines are on the market or under investigation right now, many targeted to gender-specific cancers. Along with the FDA-approved Gardasil(TM) HPV vaccine, which can prevent certain types of cervical cancer, trials are underway on the prostate cancer vaccine GVAX(R), a breast cancer vaccine, and another cervical cancer vaccine.

One important difference between all these vaccines is that Gardasil is given before any cancer diagnosis, and the other vaccines under trial that I mentioned are given after a cancer diagnosis in addition to standard cancer treatment. These post-diagnosis vaccines seem to be the trend with cancer vaccines, despite the heavy marketing of Gardasil. These vaccines are designed to "retrain" the patient's immune system to respond more effectively to proteins associated with cancer cells. Some of these vaccines are developed using the patient's own cells, and other are not.

Two promising post-diagnosis vaccines under investigation that are not gender-specific target lung cancer (the most deadly cancer among both men and women) and cutaneous melanoma (which is more deadly among men than among women).

I'm curious about the gender differences between cancer vaccines. Do women respond more favorably than men to cancer vaccines, or vice versa? Are vaccines that use the patient's own cells more or less effective than those that don't? Are vaccines for gender-specific cancers, such as prostate and cervical cancer, more or less effective than vaccines for cancers that can strike both genders? There might be no patterns here, but if there are, it would be interesting to see how physiology, sociology, and other factors impact the effectiveness of these vaccines.