Monday, November 17, 2014

November 17, 2014 — Bye, Bye Bexxar

There are many ways our market-driven healthcare-funding system in the United States is just plain crazy, but one of the most damaging is the way it tends to suppress certain vital and effective medications. This has evidently just happened to Bexxar, which is no longer available. Along with its competitor Zevalin, Bexxar is a radioimmunotherapy agent.

Radioimmunotherapy is an ingenious bonding of a monoclonal antibody drug — Rituxan (rituximab) — with tiny radioactive particles. It delivers a one-two punch: the Rituxan chemically seeks out the cancer cells and the radioactive particle destroys them.

Radioimmunotherapy has proven to be very effective, and has the added advantage of doing its job in just one dose, with minimal side effects.

What’s not to like?

The people who really don’t like it are oncologists. And why? Because not many of them have the proper qualifications to administer it. As a hybrid of nuclear medicine and oncology, radioimmunotherapy requires doctors either to be dual-certified in both disciplines or to be part of a large clinic or group where both specialties are represented (a rare thing, in this case).

Many oncologists profit on two levels: both their professional fees and the fees they charge for running a chemotherapy suite. If their chemo suite doesn’t offer nuclear medicine as well, they lose a big chunk of change by referring a patient out.

An oncologist who refers a patient for radioimmunotherapy loses tens of thousands of dollars in billable fees. That’s a powerful financial incentive to stick with traditional chemo — even though that treatment takes longer (many months of infusions as compared to a single injection) and often has arduous side-effects.

This is not a problem for a large, multi-specialty clinic, but the typical oncology practice — which includes a group of oncologists only — can’t handle it. As Dr. Bruce Cheson of Georgetown University puts it, “patients had to be referred from one doctor to somebody somewhere else, which meant not only losing control of the patient, but also losing income from the patient.”

In many cases, radioimmunotherapy agents cost less — not as a single dose, but when averaged out over the total time required for treatment.

“There is actually no other drug out there with a track record like this,” writes Dr. Mark Kaminski of the University of Michigan, who helped devlop Bexxar. “Approximately 30% of patients can achieve long-term remission with Bexxar lasting over a decade. That's the biggest disappointment with this drug, now that it's gone, for patients with this disease — it was an easy treatment, it took only one week to finish, and if there were any side effects, they were all reversible. I've been giving Zevalin lately because I don't have Bexxar to work with, but I don't have as much confidence that it will be a solution for patients as much as Bexxar would have been.”

If we had a single-payer healthcare system (like Medicare), and if doctors practiced in multi-specialty clinics like the Mayo Clinic or the Cleveland Clinic — where they receive a salary rather than billing patients by the hour — then doctors wouldn’t stand to lose by recommending radioimmunotherapy. More patients would benefit.

Why do we expect physicians to be both medical practitioners and entrepreneurs? Sometimes those two functions are in conflict with one another, and this is a prime example.

Too often in our healthcare system, profits come first and patients second.

Monday, November 10, 2014

November 10, 2014 — The Downside of Early Diagnosis

I read in the New York Times the other day about an “epidemic” of thyroid cancer in South Korea: a fifteen-fold increase in what had been, until recently, a relatively rare cancer. Thyroid cancer is now the leading cancer in that country.  (H. Gilbert Welch, "An Epidemic of Thyroid Cancer?" New York Times, November 5, 2014.)

How to account for the increase? A team of researchers set out to discover the reason.

After gathering their data and running the numbers they came up with the culprit: increased diagnosis.

Yes, diagnosis. Beginning in 1999, the government health program started paying for cancer screenings. Many doctor’s offices are equipped with relatively inexpensive ultrasound machines, so they naturally ordered up the test. Drastically increase the number of screenings and you’ve got — you guessed it — a greater number of diagnoses.

It’s not that there was an increase in thyroid cancer. There was an increase in the ability to diagnose the cancers that were already there.

That may seem like a good thing, but it’s actually a bit more complicated than that. As the article goes on to explain:

“Where did all those new thyroid cancers come from? They were always there. As early as 1947 pathologists recognized that, although it was a very rare cause of death, thyroid cancer was a frequent finding during autopsies. Studies have since shown that over a third of adults have thyroid cancer. Virtually all of these cancers are small ‘papillary thyroid cancers,’ many of which will never become evident during a person’s life.

Unless that person receives a screening ultrasound. In fact, virtually all the newly identified thyroid cancers in Korea are papillary thyroid cancers. How do we know this is not a real epidemic of disease? Because the number of Koreans dying from thyroid cancer has not changed. If the screening were saving lives, the death rate would decline, or increase more slowly as the epidemic spread — but not stay perfectly flat.”

I was diagnosed with papillary thyroid cancer a few years ago and had my thyroid gland removed. I had no physical complaint at the time. I wouldn’t have known I had it, were it not for the regular CT scans I was having at the time (monitoring me for a recurrence of lymphoma).

I take a thyroid-hormone replacement pill (Synthroid) every day, and calcium supplements (Extra-Strength Tums) twice a day, because my blood tests following the surgery indicated calcium deficiency (a common side effect of thyroid surgery, due to damage to the nearby parathyroid glands). That’s no great inconvenience, but if I went a couple of weeks without my Synthroid, I’d be pushing up the daisies.

Was my surgery necessary? Would watch-and-wait have been more appropriate? There’s no way to tell for sure. Complicating the decision, of course, was the fact that I was already a cancer survivor at the time the thyroid tumors were found.

Still, I wonder...