Treatment Costs for Metastatic Breast Cancer
With few exceptions, the newer drugs still under patent are extremely costly to patients, private insurers and Medicare, Medicaid, and public insurance programs like Medi-Cal. Unlike adjuvant treatment for primary breast cancer, metastatic breast cancer patients typically receive continuous treatments throughout their lives. Typically, the drugs that metastatic breast cancer patients use and the tests, doctors visits, and other medical care to administer these life-prolonging treatments run into many thousands of dollars each month for each patient. With new treatments extending lives, the costs, of course, will increase proportionally.
Given the current state of spiraling health care and insurance coverage costs, combined with a larger population of uninsured and underinsured in the United States, it would not be surprising to learn that availability of these expensive new drugs is not equally distributed across all races and classes. In fact, equity in access would be surprising.
These financial realities have serious implications for patients with high-risk and metastatic breast cancer, and may account for many lives lost and shortened. These are areas that cry out for extensive study and research.
These escalating costs may be more problematic for women with metastatic breast cancer, than for primary breast cancer patients currently, and in the future. More and more, oncologists speak of treating metastatic breast cancer as a chronic disease. In the metastatic setting, where the 97 percent mortality figure is still considered accurate, the continuing extension of life in the direction of chronic disease is an important goal. The MD Anderson study, cited previously, offers persuasive evidence that 40 percent of patients optimally treated at their center now live five years or more with distant metastatic disease. That number is surely growing, as available agents increase and as refinements in treatment are made.
Further evidence comes from a recent Canadian study from the British Columbia Cancer Agency presented at the most recent meeting of the American Society of Clinical Oncology (ASCO) examined the impact of new treatments for metastatic breast cancer on length of survival.62 Prior to this study, there had been no population-based study that demonstrated that length of survival in 2,151 metastatic patients had improved from the oft-quoted median survival of 12–24 months. The study linked to a pharmacy database to look at the impact on length of survival of drugs approved from 1991–2001, the period during which Taxol, Navelbine, Taxotere, the aromatase inhibitors, Xeloda and Herceptin were approved for use in Canada. During 1991–1992, median survival was 434 days, with 34 percent of patients surviving two years or more. By 1999–2001, median survival had increased to 661 days, and 45 percent of patients were still alive at two years. It seems reasonable to assume that access to these new treatments does prolong life.
During the entire time a patient is being treated, periodic testing should be done to follow the disease and assess treatment response. Tests for this purpose include (but are not limited to) MRI and CT scans, PET and bone scans, X-Ray studies, tumor markers, and liver function tests.
It is common now for women with metastatic breast cancer to have multiple lines of hormonal, chemotherapy, and biologically targeted therapies over a period of years—that is, if they are fortunate enough to have the means, knowledge, and access to these treatments at the hands of skilled oncologists. Knowing what we know about differences in mortality rates between black and white women, this scenario raises certain inevitable questions—questions to which we don't as yet have answers.
Will a newer, more expensive treatment be offered to an elderly metastatic breast cancer patient, for example, after the second or third or fourth line of treatment has failed her? Will she be able to travel to get her treatments on public transportation, or can special arrangements be made for her to get to her doctor's appointments if she is ill or disabled? Will someone make sure she has needed family support during the long course of her illness? Will her case be carefully followed with blood tests and scans to assess whether treatments are working or should be discontinued? Will she have access to newer hormonal therapies or targeted biologics in a dedicated attempt to extend her life and offer her good quality of life? Will she be offered supportive medications to ease her pain or nausea? Will her comorbid conditions and risk/benefit factors be carefully addressed?
All of these interventions are becoming increasingly costly. Documentation of the dollars spent in treating metastatic breast cancer in California, as well as any potential disparities in such expenditures on behalf of different patients across racial/ethnic, socioeconomic and age groups would clearly provide important data for health policymakers. It would be important to understand what treatments are received by women with advanced breast cancer, including any reliance on indigenous healing practices.