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Medical community uneasy over money vs life debate

  • January 14, 2017
  • , Mainichi , p. 10
  • JMH Translation

The very expensive cancer treatment drug Opdivo and its impact on the nation’s welfare system have resulted in a growing awareness within the medical community of drug costs and optimal usage of medications. Last December, lung cancer specialists involved in treatments using Opdivo gathered at a medical society meeting where voices from both sides were heard, with calls for consideration of costs and expressions of ambivalence about this new trend.


At the Japan Lung Cancer Society meeting held in Fukuoka City in December 20, 2016, a medical economist and doctor, Toshiya Ikeda of the International University of Health and Welfare, spoke to a symposium titled “Optimum lung cancer treatment from the medical economic perspective.” He said: “We in the medical community have been educated to treat patients in front of us as best we can by utilizing advanced technology where possible. That is still the most important thing for us. But we must also consider social resources to make a comprehensive decision. That will be the role of doctors who treat patients in the future.”


Ikeda also said, “Drug cost adjustments will be meaningless if medical professionals are not cost conscious.” He urged society to engage in discussions on how doctors should use drugs and how the medical community should incorporate the aspect of “cost effectiveness” in treatment guidelines the society formulates.


Meanwhile, some meeting participants voiced skepticism about introducing cost factors in treatment planning. One hospital doctor said, “Some younger doctors have started to harbor discriminatory thinking such as, “Why  treat older patients with such expensive drugs?’ Even expensive drugs gradually become less expensive (after price revisions). Shouldn’t we just think of the patients in front of us and the effect of a particular medication on them, rather than worrying about its cost?” There is deep antipathy toward discussions that involve lives versus money.


Hideo Kunito, head of the chemotherapy department at the Japanese Red Cross Medical Center, also attended the symposium. Kunito has been raising the issue of the burden of expensive drugs such as Opdivo on the national treasury. He said, “It is easy to say that we will save every patient. However, if (a financial) collapse occurs, that would mean abandoning the younger generation.” He pointed out that the medical community needs to determine the optimal use of expensive treatments including choosing a less expensive option if it is equally effective with the same adverse effects, finding out who can expect an improvement from using an expensive medication, as well as finding out who is not going to benefit from the administration of the expensive medication at an early stage of the treatment.


Nobuyuki Yamamoto from Wakayama Medical University, the chairman of a committee that formulates treatment guidelines for the society, said: “An argument is gathering momentum for drawing up guidelines with cost considerations in mind. However, we don’t know where this argument will lead as there has been no precedent.” In the U.S. and in Europe, the increasing cost of drugs such as Opdivo has been gaining attention. But there has not been any mention of drug costs in any of recent lung cancer treatment guidelines. The medical economist Ikeda noted, “In hospitals and clinics, there is not even a consensus as to ‘let’s use the less expensive option if the effect is the same.’ So far, the guidelines concentrated on issues of effectiveness and safety of treatments. From now on, practitioners need to consider the value of a treatment from a social point of view, including its cost.”


Treatment scope expands for Opdivo, new options become available


Opdivo was introduced in December 2015 for treatment of non-small cell lung cancer, which accounts for 85% of lung cancers. So far in Japan, more than 10,000 patients have been treated using Opdivo, which cost about 35 million yen per patient per year. Under the Japanese system, the majority of the increased cost is paid for by the national health insurance and taxes, and the wide use of expensive drugs is a direct drain on the national health budget.


Since only about 20% of the patients are expected to benefit from the use of Opdivo, the Ministry of Health, Labor and Welfare formulated a guideline last December with cooperation from related academic societies that promotes the optimal use of Optivo.


The guideline encourages doctors, when deciding whether or not to treat a patient with Opdivo, to conduct a test to determine the amount of PD-L1 produced by cancer cells targeted by Opdivo. If the expected effect of Opdivo is determined to be about the same as that of an existing cancer treatment medicine, the guideline recommends doctors opt for using the existing drug.


Opdivo increases the body’s immune function to combat cancer. As such, it may trigger an overreaction of the immune system with adverse effects. Because of this possibility, the guideline requires a medical institution that administers Opdivo to have appropriate systems, facilities, and a doctor in charge with experience and knowledge of the adverse effects. The guideline will be issued nationwide by the end of this fiscal year.


Last December, an application was approved for Opdivo to be used to treat stomach cancer as well, from which many suffer in Japan. This year, a rival drug that has the same effects as Opdivo will become available as a lung cancer treatment option. Opdivo is used in treatment of patients who have already been treated with other anti-cancer drugs. On the other hand, Keytruda (generic name: pembrolizumab) can be used as a first-line treatment for patients with high levels of PD-L1. A study has proven Keytruda to be more effective compared with existing anti-cancer drugs as the first-line in treatment of patients who cannot be operated on.


Anti-cancer drugs with the same effect are being developed by multiple pharmaceutical companies. Their prices and expanded use will be the focus of attention.


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