Weighing the evidence – should Ontario fund Avastin for brain cancer?
Like many Ontarians, I have been moved by the request of Kimm Fletcher to have the Ontario government pay for the drug Avastin to treat her recurrent brain cancer. Ms. Fletcher is 41 years old and the mother of two young children. It sounds like her brain cancer is growing aggressively despite the best treatments her doctors have provided. How can one not feel a huge amount of sympathy for her?
It has been pointed out that some provinces do pay for Avastin for brain cancer, and the implication seems to be that those provinces have it right, and Ontario doesn’t. Perhaps it is the other way around.
Most media reports have failed to mention, or have under-emphasized, some things that I think are important to consider.
First, Avastin unfortunately doesn’t appear to work very well in people with brain cancer. Two recent quite large studies in which hundreds of people with brain cancer were randomized to either receive Avastin or not found no difference in survival between those who were treated with Avastin and those who were not. Avastin may have a small benefit on the growth rate of the tumour, but that needs to be balanced with the side-effects of the drug, some of which can be severe.
Second, Avastin is very expensive – around $100,000 per person per year.
I am surprised that none of the media stories I have read have asked how a drug company can justify charging $100,000 a year for a drug that has so little benefit for people with brain cancer. It sure isn’t because there is a small market for the drug. Avastin is beneficial for people with cancers other than brain cancer (particularly colon cancer, for which it is funded by the Ontario government) and world-wide sales of Avastin in 2012 were about $6 billion.
In focusing on the government’s unwillingness to pay for this drug, I think we have neglected to ask the important question of whether the price the government is being asked to pay is reasonable. Given that publicly funded health care resources are not unlimited, I don’t think it is.
Some will argue that there is considerable waste in health care (inappropriate tests, unnecessary physician visits, poorly coordinated care, etc.) and that it isn’t fair to hold drugs to a higher standard than most of the rest of the system. I agree with the concerns about waste, but I think we should strive to have the rest of the system make better use of value-for-money evidence when allocating resources, rather than abandon that approach for drugs.
However, I do believe the Ontario government owes Ms. Fletcher, other patients and the public an up-to-date explanation for why it isn’t paying for Avastin for people with brain cancer. Unfortunately, the most recent explanation that I could find was from October 2011. At that point, there was no good evidence that Avastin was beneficial for people with brain cancer. It is time to bring this up to date.
Finally, I should clarify that I am not questioning the right of individuals to aggressively advocate for access to treatments they feel are beneficial. In 2011, Jill Anzarut, raised important questions about Ontario’s approach to paying for Herceptin for people with small breast cancers. Her advocacy, and media coverage of it, accelerated important changes to Ontario’s approach to funding Herceptin. However, the change was based upon information from research which had shown that Herceptin was beneficial for some types of breast cancer.
The media’s coverage of personal appeals, and our reaction to them, should have an appropriate balance of empathy and realism. When Ms. Fletcher says “If this [Avastin] gives me an extra year to live….”, I think it is important to point out that, unfortunately, this is highly unlikely. When the drug company is charging $100,000 a year for Avastin, I think it is reasonable to say that the publicly funded health care system should not pay for the drug in these circumstances. Ms. Fletcher has launched an appeal for donations so she can pay for the drug herself – I hope that she proves all of the studies wrong.
Andreas Laupacis is the editor-in-chief of Healthy Debate. Follow him on Twitter @andreaslaupacis