For a few months of living advantage

Are the colossal sums spent on anti-cancer drugs worth the final outcome?

by Dr. Mahendra Perera

With nearly 20,000 new cases diagnosed each year cancer is obviously on the rise. Cancer care is not a ONE-TIME treatment. There are many patients surviving with their cancer cured, controlled or uncontrolled. More than half of these patients would require second time treatment, or even third, fourth time, which makes them finally incurable.

Cancer care is basically a multi-modal treatment based on Surgery, Radiotherapy and Chemotherapy, the latter which consists of thousands of anti-cancer drugs, which are toxic to the Cancer and to the patient's normal organs. Anti-cancer therapy is designed by the Oncologists in a manner that would bring minimal side effects to the patient with maximal destruction to the cancer.

Many conventionally designed anti-cancer drugs used for years on cancer patients in the past have shown proven benefit in controlling cancer and some of them have even brought cancer cure. Additionally, thousands of newer molecules are being manufactured by the pharmaceutical industry to market in cancer treatment, which would sometimes cost over a couple of millions of Sri Lankan Rupees per single patient.

Adding such newer agents would add some survival advantage on long-term basis in a minority, but the majority of such agents have in fact brought nothing or a just few months of living advantage to a patient.

It is worthwhile that we look in to this aspect of unacceptable health resource drainage on exorbitant newer drugs of doubtful benefits.

The majority of cancer patients would most helplessly agree with whatever Chemotherapy suggested by the Oncologist.

At whatever cost

They even request the Oncologist to give any drug at whatever cost to cure them. But do such high cost drugs really cure them? Is it worthwhile giving a drug costing a couple of millions to try and prolong a terminally ill cancer patient's life by few months? Not at all! It would only add intolerable side effects that would deprive the patient's last few days of quality.

It is much more sensible and appropriate to arrange a good palliative care programme, which would not only offer them almost the same probability of life with an excellent quality without drug induced mutilation.

Cancer patient collapses in all social aspects including their finance. Their family members suffer along with the patient looking for an avenue to rescue the patient even by selling their all property or valuables. By the time most of these patients come to the oncologist their finances are all exhausted.

But they still say to the oncologist to do the best at whatever cost without realizing the meaning of cost in cancer treatment.

Today, a course of properly designed radiotherapy varies from Rs. 500,000to Rs 1,000,000 (1million) in the private sector. Again a course of cancer chemotherapy varies from Rs 50,000to Rs. 5,000,000 (5 million), depending on the type of cancer and the drugs used in combination.

The Minister of Health recently implemented a project to equip each government cancer centre in the island with a Linear accelerator machine that could treat cancer patients to equal standards or even more than in the private sector.

Variable efficiency score

This was estimated to cost the government a sum of 52 million USD. By the end of this year 2015, every government cancer treatment centre would be able to deliver LINAC based best quality radiotherapy to all the cancer patients in Sri Lanka, with comparable or even superior to any other centre in the world.

With regard to the special cancer drugs in addition to the conventional chemotherapeutic drugs provided to Cancer hospitals and cancer units in the island, the ministry of health has offered an invaluable process called 'Named Patient Basis Drug Provision' through the Medical Supplies Division (MSD) in association with the State Pharmaceutical Corporation (SPC).

This process provides any drug requested by the oncologist valued up to Rs 1.5 million for a single patient per year. The procedure of purchasing special named patient drugs has been taken over by the National Cancer Institute - Maharagama now. This is considered a well-monitored procedure, which provides the patients drugs without an undue waiting time.

Today, there is an extra budget of Rs15 BILLION, to purchase over 60 exorbitant drugs, which have a very variable efficiency score from 0 to 75%. None of these are 100% effective in cancer. Despite all, a variable proportion would certainly recur, because these drugs are used on the basis of clinical evidence.

It is an utter waste of money and drugs. Not only do they not respond, they also suffer due to unwarranted toxicity. The answer to this waste is to practice Genomic Based Personalized Chemotherapy that has a greater strength in excluding the most non- responding drug and give the benefit of the most appropriate drug to the patient. This concept of 'Personalized Medicine' is not only confined to Cancer treatment but has also been extended to many other disciplines of medicine.

The key factor is a Validated 'Bio-Marker' for a particular cancer in a particular person. It is well accepted that undue waste of these expensive newer molecules and their cost could be significantly reduced. Further it would improve the efficacy of the treatment outcome while minimizing the toxicity and unwanted side effects of changing many toxic drugs on patients one after the other.

(Dr Mahendra Perera, MBBS, MD, Dip.RT is Consultant in Clinical Oncology & Radiotherapy)