How much is a life worth? What price can we put on extending a life for a few years, a few months or a few days?
Increasingly, those are questions that, however unsettling, need to be asked, particularly in the cancer field.
There are a growing number of cancer therapies. They are increasingly expensive.
And many produce only a short extension of survival. That combination can pose some serious dilemmas, clinical as well as ethical.
The issue is underscored by a recent article in the Journal of the National Cancer Institute.
Tito Fojo, a medical oncologist at the U.S. Center for Cancer Research at the National Cancer Institute, and Christine Grady of the department of bioethics at the U.S. National Institutes of Health.
The pair published some hard data on the costs and benefits of several high-profile cancer drugs that help provide some important perspective for this discussion.
Here are some examples to ponder:
Cetuximab (brand name Erbitux) is a drug used to treat lung and colorectal cancer. Treatment costs $80,352 (U.S.) and increases survival by 1.2 months.
Bevacizumab (Avastin) is used to treat lung, colorectal and breast cancer. A course of treatment costs $90,816 and it extends survival by 1.5 months.
Erlotinib (Tarceva) is used to treat lung and pancreatic cancer. Treatment costs $15,572 and the drug extends survival by 10 days.
Sorafenib (Nexavar) is used to treat kidney cancer and advanced skin cancer. A course of treatment costs $34,373 and it extends survival by 2.7 months.
These figures are, in themselves, thought provoking. But they tell only part of the story.
Every one of the cancer drugs cited is essentially a drug of desperation. They are used only after many other surgical interventions and drug treatments have failed.
As with all drugs, there are also side effects, in many cases debilitating ones. This reminds us that survival needs to be measured in more than days kept alive.
Let's take a more in-depth look at one of the drugs, cetuximab. It was a highly anticipated drug because it tackled cancer in a new way.
In May of this year, the medical journal The Lancet published the results of a study about the use of cetuximab to treat non-small-cell lung cancer.
The researchers concluded that adding the drug to the standard platinum-based chemotherapy drugs cisplatin and vinorelbine "sets a new standard" for the treatment of patients.
One month later, at the conference of the American Society of Clinical Oncology, which is considered the world's most important cancer meeting, it was stated that the findings "are likely to have a significant impact on the care of patients."
Neither the published paper nor the press briefing touting the wonders of the drug underscored that many patients treated with cetuximab suffered severe febrile neutropenia (a combination of fever and low white blood cell count that puts patients at risk of infection), along with diarrhea and rashes.
Nor do those singing the praises of the drug much like to talk about its cost. The $80,000 cost for an 18-week treatment is also misleading. That is the cost of the drug, and does not include the time of health professionals to perform the infusion and related tests nor the cost of treating side effects.
In their paper, Dr. Fojo and Dr. Grady offered this dispassionate analysis of the data: "The only reasonable conclusion is that a magic anti-cancer bullet aimed at an important target missed by a wide margin."
They describe cetuximab, bluntly but fairly, as a "treatment offering marginal benefit at very high cost."
Survival rates for most cancers have risen steadily for a number of years. But cancer is still a big killer.
Last year, an estimated 166,400 Canadians were diagnosed with cancer and about 73,800 died.
In cancer treatment, everyone hopes against hope but, at some point, the disease often gets the upper hand.
As treatments become more desperate, we need to ask ourselves some tough questions, many of which Dr. Fojo and Dr. Grady set out in their paper: What should count as a benefit in cancer treatment? What is the minimum amount of benefit required to adopt a new drug therapy? In the case of cetuximab, is 1.2 months of additional life a "good" in itself? Or does the quality of life during that time matter? And does cost matter?
There are those who will protest that cost should not be an issue when treating someone with a grave illness such as cancer. But, however callous it may seem, cost must be an issue and a cost-benefit analysis must be done.
In our health-care system, money is not unlimited. The $80,000 spent on cetuximab to potentially extend a person's life by a few weeks could be used in other ways and, undoubtedly, to more effect.
For example, is money best spent on a desperation drug with limited effect or on palliative care for dying cancer patients?
The all-too-common practice of administering new, marginally beneficial drugs to dying cancer patients is a losing proposition, for the patient, the health system and society at large.
Yes, every life is precious, some would say of infinite value.
But we have to stop deluding ourselves. People will die of cancer. Every reasonable effort should be made to ensure a good life and a good death.
But that does not mean mindlessly throwing huge sums of money at so-called miracle drugs.
Quality of life matters - for everyone.
