Planning a budget for cancer treatment

Planning a budget for cancer treatment

It is next to impossible to financially plan for cancer treatment.

Take one cancer scenario: EGFR-mutation-positive adenocarcinoma of the lung. This is one subset of lung cancer not uncommonly encountered.

In the US, 10,000 such cases are diagnosed each year; in the world, about 100,000.

In Malaysia, a guess estimate would be 800. The treatment of choice for this subset of lung cancer is either gefitinib or erlotinib.

The cost of treatment is RM10,000 a month (S$4,000). This covers the cost of the drug and other incidentals.

How long must the patient take this cancer drug? The answer is, "as long as the drug works".

Which only begs the next question: "How long will the drug work?"

And this is the tricky part. In some patients, the drug is no longer effective after two months.

In about 5% of patients, the drug keeps the cancer in check for four years or more.

The rest lie in between.

I will tell you with a straight face and an unwavering voice that you will have to budget between RM20,000 and RM480,000 for this treatment, for this particular cancer.

And yet despite this range, I will be perfectly correct and scientifically sound.

Take another scenario: metastatic cancer of the colon, K-RAS wild type.

Again, the number of patients with this cancer is not small, almost as many as the lung cancer subset we discussed.

Seminar after mind-numbing seminar, we are taught that the best results for patients with this subset of colon cancer are obtained if you use up all six effective drugs: 5-fluorouracil, leucovorin, irinotecan, oxaliplatin, cetuximab, and bevacizumab.

We are also taught that liver metastases (spread to the liver) should be resected whenever possible.

If we do our best for patients with this cancer, some will live for six months, and some other fortunate ones live four years or more.

And the cost of treatment? Between RM240,000 and RM1.5mil.

If my figures are wrong, they are wrong on the conservative side.

 

In HER2 positive metastatic breast cancer, two molecularly targeted drugs are used: trastuzumab and lapatinib.

They are usually used together with conventional chemotherapy.

Again, the answer to the question, "How long must the patient be on the drug?" is "Until the disease becomes worse."

And this can be anything from six months to five years or more.

Stopping treatment prematurely will make the disease that much worse.

The cost of treatment is very high. Trastuzumab also costs about RM10,000 per month.

The sad thing is that many patients go off treatment because they can no longer afford it.

There are 50 other common cancer scenarios, and in each, budgeting puts the budget planner (be it the patient, the relative, the government, the employer, the insurance or whoever the payor is) in a quandary.

Advanced cancer is a predictable disease when it is not treated with surgery, radiotherapy and drug therapy.

The patient suffers pain, agony and indignity and lives for anything between six months and two years.

If treated appropriately, it becomes unpredictable. Survival times vary greatly with treatment.

Patients respond differently to cancer drugs. Some will live for about six months and others survive for four years and more.

The cost of a good quality life using the best available drugs will vary accordingly.

I don't have the answers, but I have many questions. Shall we adopt a system (favoured by some countries) that for expensive cancer drugs, either all get it or none get it?

Wouldn't that be discriminatory against those who are willing and able to pay?

Shall we not tell our impoverished patients about expensive cancer treatment?

This is to spare them the pain and agony of knowing that they are not having the best possible drugs.

Isn't withholding this kind of information medically unethical?

Shall we spend half our salaries on large medical insurance premiums knowing that only a very small proportion of us will have to face the agonising physical, emotional and financial travails of cancer?

Shouldn't we all be philosophical and accept things as they come?

Should we be prepared for all and any eventuality in life, however remote?

Of one thing I am sure. All questions are on the table and must be discussed with candour and courage.

Let us come up with a few provisional answers and take the first few tentative steps.

Otherwise I shall be belabouring this theme in 10 years time.

Dr Albert Lim Kok Hooi is a consultant oncologist. For more information, email starhealth@thestar.com.my.

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