[BLOG] Blessings in disguise Should formularies welcome premium-priced bladder cancer drugs?

The management of bladder cancer represents one of the most costly and underestimated challenges in the oncology spectrum. Despite having the 6th highest incidence of any cancer in the United States, high recurrence rates and the need to constantly monitor patients act as the primary drivers for the high expenditures associated with the disease.

With only approximately 70,000 new cases in the United States every year, and that disease outcome (compared to other cancer settings) is relatively good and patients can live for several years with the disease, bladder cancer is not considered the most pressing challenge in oncology. Prevalence data from the SEER (Surveillance, Epidemiology, and End Results) program of the National Cancer Institute indicate that 500,000 individuals are currently living with bladder cancer in the United States.¹ High recurrence rates, however, which can be as great as 70% in some cases, combined with the need for repeat treatments and consequent patient monitoring between administrations, are key factors for escalating healthcare expenses. Indeed, bladder cancer has the highest diagnosis-to-death cost of any cancer, and comes in as the fifth most-expensive setting in oncology, accumulating an annual US expenditure of approximately $3.7 billion, a huge financial burden for healthcare systems and patients alike.²

Approximately 75% of costs post diagnosis correspond to managing postsurgical complications, as well as triannual monitoring examinations and semiannual diagnostic and laboratory tests. Furthermore, researchers found that 60% of the bladder cancer cost burden was primarily associated with recurrence rates and surveillance.³ The treatment of complications alone accounted for 30% of the total costs. The surgical procedure TURB (transurethral resection of the bladder) also represents one of the highest expenditures, as patients with low-grade Ta (the most common form of bladder cancer) can observe multiple recurrences, costing up to $5,300 each time in the United States. As bladder cancer progresses so does its price tag; patients with muscle-invasive disease who have failed chemotherapy or patients with high-risk nonmuscle-invasive disease who have failed drug treatment will be prime candidates for a cystectomy (bladder ablation). Another study found that the median cost for a cystectomy in the United States was approximately $50,000, and with complications occurring in approximately 28% of patients the cost of treatment could further increase by $15,000.^4,5

By contrast, the price of drugs make up a relatively small proportion of the healthcare cost burden associated with bladder cancer. In a recently published GlobalData report the total US sales for drugs (including both branded and generic products) were determined to be $139 million in 2012, translating to average sales of approximately $2,000 per newly diagnosed patient.⁶ By comparison, total sales for pancreatic cancer drugs in 2012 accounted for approximately $300 million, despite the disease having half the incidence of bladder cancer, and 13 times lower prevalence.⁷ These substantial differences between cost of drug therapy and overall expenses set bladder cancer apart from many of the other oncology indications. It also opens the opportunity for new drugs to drive down the overall disease management cost in the long term by circumventing the need for regular patient monitoring, invasive surgery, and the costly complications associated with it.

With a weak competitive landscape primarily consisting of generic chemotherapies (mitomycin C, cisplatin, gemcitabine) and a 30-year-old immunotherapy (bacillus Calmette-Guérin [BCG] immunotherapy), opportunities for new drugs to enter this space and improve disease outcomes are real. Even modest improvements in recurrence rates or time to disease progression that would facilitate less-frequent monitoring would ultimately translate into cost-saving benefits. Recently, the price of cancer drugs has been under the spotlight because of the argument of little disease improvement versus high disease expenditure; however, bladder cancer is the perfect example of a setting in which premium pricing should in fact be encouraged. Such an action should cultivate interest from the larger drug developers who have historically kept at arm’s length from this setting. Publically acknowledging the need for innovative medicines along with promises of high price tags should be the way to convince these drug developers to invest in this field. Such interest would not only benefit patients but also the whole healthcare environment, including payers. Once these new drugs are here, formularies should welcome these premium-priced blessings in disguise!

Mr Ali is GlobalData's analyst covering oncology and hematology.

References

1. SEER (Surveillance, Epidemiology, and End Results Program). SEER Stat Fact Sheets: Bladder Cancer. National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services. 2014, http://seer.cancer.gov/statfacts/html/urinb.html. Accessed February 20, 2014.

2. Milowsky M. Clinical trials in bladder cancer: necessary but challenging. UNC Cancer Center. 2012. http://www.bcan.org/wp-content/uploads/2012/10/Milowsky-webinar-1.pdf. Accessed February 20, 2014.

3. Avritscher EB, Cooksley CD, Grossman HB, et al. Clinical model of lifetime cost of treating bladder cancer and associated complications. Urology. 2006;68(3):549–553.

4. Konety BR, Allareddy V. Influence of post-cystectomy complications on cost and subsequent outcome. J Urol. 2007;177(1):280–287.

5. Sievert KD, Amend B, Nagele U, et al. Economic aspects of bladder cancer: what are the benefits and costs? World J Urol. 2009;27(3):295–300.

6. OpportunityAnalyzer: Bladder Cancer – Opportunity Analysis and Forecasts to 2017. London, UK: GlobalData; December 2013.

7. OpportunityAnalyzer: Pancreatic Cancer – Opportunity Analysis and Forecasts to 2017. London, UK: GlobalData; publication scheduled February 2014.