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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

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8 comments

  1. Kathleen Finlay | Patient Protection Canada

    The fact of the matter is that as long as Ontario’s healthcare system, and its decision-making process, are hobbled by such a weak and dysfunctional system of accountability, patients and families can have little confidence in the decisions being made or whose interests are being served. Indeed, too often users of the healthcare system are confronted by a culture of delay, denial and deception. And too often, this means that patients and families have to battle hospitals and healthcare bureaucracies at the same time they are fighting illness or disease. This will not change until a more robust ethic of accountability is created. We are attempting to play our role in that urgent mission at http://www.patientprotection.ca.

  2. Maureen Taylor

    I think Dr. Laupacis raises important points and I’m also disappointed by the media’s laxity in looking at the evidence before featuring these obviously tragic and desperate patients. I heard Ms. Fletcher interviewed on Metro Morning and she stated that her oncologists told her that Avastin would extend her life – why would they tell her that? I feel her doctors are partly to blame here too. Finally, let’s remember that Avastin, while expensive intravenously in large doses for colon cancer, was found to be beneficial in tiny amounts when injected into eyes to slow age-related macular degeneration. It cost about a hundred dollars an injection when used this way. But the drug company that makes Avastin (Genentech) insisted on marketing a twin drug for ARMD called Lucentis, which was patented separately and of course, cost hundreds of dollars more per injection than Avastin. Provincial governments had no choice but to pay for Lucentis because it could not pay for the off-label use of Avastin for ARMD. We need to hold these pharmaceutical companies accountable for this type of greed.

    • Kathleen Finlay | Patient Protection Canada

      Ms. Taylor,

      You raise important points, as always. But on the notion of holding private pharmaceutical companies accountable, how would this be done when it seems that the public, and certainly patients and families who have been harmed, are unable to hold their own public healthcare system accountable for its actions in almost any clinical setting. Without addressing the wider challenges about transparency and accountability, the safety of more and more patients, and more and more decisions affecting them, are bound to be compromised.

      ~Kathleen

  3. Yan Xu

    I agree wholeheartedly that a more balanced approach to reporting is needed on the topic of funding expensive therapy with questionable efficacy. Rather than saying “why wouldn’t the government fund these expensive drugs,” we ought to take a step back and wonder, “why are these drugs so expensive in the first place?”

    Almost universally, we accept patented drug pricing as an unquestionable constant from the pharmaceutical industry, one of the most profitable sectors worldwide. While it may be easy to direct blame to government, one often does not realize that each dollar that is spent on medication coverage is a dollar that is taken away from public health, support for persons with disability, education, or any other service provided by government. It is bewildering why there is so little attention paid to the pharmaceutical industry as a player in the accessibility issue.

    The level of reach that mainstream media enjoys, in my mind, comes a high threshold for accuracy in journalistic reporting. I believe future reporting ought to both be reflective of evidence and committed to tackling the complexity of issues. It is unfair to reach for the “low-hanging fruit” of attacking policy-makers, whom I genuinely believe are making the best decisions they can within competing demands and priorities, rather than the callous, unfeeling individuals as portrayed by media.

  4. Jennifer Shane

    “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.”

    Yes, although the pharmaceutical companies are making 6 billion dollars a year on this medication, Avastin, but it requires a HUGE amount of effort and time to develop a “break-through medication”, like this one. On average, only 1 in every 100,000 drug originally tested can approved by the FDA and is commercially available on the market. First, pharmaceutical companies must invest in research and isolating the active drug ingredient, then they perform multiple tests to see if the drug is toxic, potent, and effective in treating the symptom. After that, they must go through 3 phases of clinical trials involving approximately 10,000 participants. This process is extremely EXPENSIVE and it takes around 10-12 years. Throughout the process, they have to estimate how many people will be using this medication, what if the competitors modify the drug and come up with something similar that minimizes another side effects and are potentially better. Thus, when a patient is paying for a drug, they’re not ONLY paying for what’s in the drug, but they’re also paying for all of the processes involved in labour, researching, manufacturing, and anything they’ve invested in the process. I don’t think the pharmaceutical companies are over charging for this drug. This profit generated would go to research for better, more efficient treatments in the future.

    • Dr Jennifer Marsden

      I would value this argument more if the profits generated all went to research, but a lot of it goes (in the US) to advertising to clinicians and in some cases patients. And the competitive nature of warring businesses trying to AVOID or ward off improvements of a drug lest it cut profits? Certainly not in the best service of humankind.

  5. tina runkles

    It seems that hey have indicated through randomized drug testing Avastin does not work for brain cancer patients. Although one empathizes with a young mother with 2 children, financailly speaking, it does not make sense to spend 100,000 dollars on a medication which may or may not work. There are also terrible side effects. You need to try to get the patient to consider quality over quantity and if the side effects outweigh the benefits for her. I would be against providing the medication.

  6. Regina Onzy

    Expense continues to be an issue when it comes to treatment for patients.

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