Monday, 13 November 2017

Measuring the value of anti-cancer drugs

Cristina Roure



Anti-cancer drugs, especially palliative drugs, are toxic, costly and sometimes of little benefit, as a result their value to the patient and society are often questionable. It’s also true that significant improvements in the survival rates are threatened by the difficulty in accessing them, due to their unsustainable cost.

Some scientific societies, such as the American ASCO, but also the European ESMO and other organizations, are developing instruments to quantify the value of cancer drugs. The objective is to provide clear and unbiased information for governmental or syndicate decision making, regarding the access to drugs and to synthesize, in a single metric, the balance between the magnitude and the relevance of the expected clinical benefits and its cost, that is its value. See what it’s all about in this video presentation of the instrument developed by the ESMO: Magnitude of Clinical Benefit Scale (ESMO-MCBS):



JAMA has published an excellent article (1) that compares five of these tools and is accompanied by an editorial (2) that points out its strengths and weaknesses. Reading the article, I thought that it would be very difficult to establish a universal value in the treatment of cancer because, as Michael Porter points out, defining health value implies clearly defining common goals that unite the interests of all parties (3). Some interests, such as accessibility, effectiveness, safety and cost are convergent and all are included in one way or another in these tools. But there are others, which, because they are linked to the individual characteristics and values ​​of each person, or are not common variables in clinical trials, are not included, despite being extremely important.

Consider the case of those elders in the group with the highest incidence of cancer and account for 70% of deaths from this disease (4), but are under-represented in most of the research in oncology, a fact that conditions that all decisions must be taken from the extrapolation of results. Neither do we choose the most interesting variables for the elderly with cancer, such as the benefit they would obtain in terms of personal independence, maintenance of functional capacity, comfort or convenience and burden of treatment, toxicity and efficacy in a situation of multi-morbidity and poly-pharmacy. Oncology clinical trials, on the other hand, focus on overall or progression-free survival, variables thought for the younger population, in which the primary goal is to delay premature cancer death.

Investigations carried out in elderly populations demonstrate that more than 40% of elderly people with cancer notice a deterioration of their capacity to perform instrumental activities of daily living and, although there are tools to evaluate functional dependence or to stratify risk of toxicity of chemotherapy in the elderly, such as the Karnofsky index (4), in clinical oncology studies are absent.

As survival time lengthens and cancer becomes a chronic disease, it’s more necessary to develop new models of geriatric oncology care with a comprehensive view of the person with cancer that contemplates comprehensive geriatric assessment, which integrates, among others, some elements as important as co-morbidity and poly-pharmacy. In the video, Professor Hans Wildiers, an oncologist at the University of Leuven, discusses his experience in implementing comprehensive geriatric assessment in elderly patients with cancer.



We welcome therefore the initiatives of ESMO, ASCO, NCCN, ICER and the abacus drug calculator of the Memorial Sloan Kettering Cancer Centre, because they represent a rigorous effort to rationalize access to new drugs against cancer, but let’s admit that it will be necessary to widen our horizon if we want more person-centred tools that provide a more adequate response to individual decision-making.

As Margaret McCartney says, the pursuit of higher-quality health care necessarily involves a bifocal vision: a relentless campaign to promote new models of evidence synthesis combined with a strong commitment to people-centred care based on respect for diversity and individuality of values ​​and preferences (5).


Bibliography

1. Chandra, A, Shafrin, J, Dhawan, R. Utility of Cancer Value Frameworks for Patients, Payers, and Physicians.JAMA. 2016;315(19):2069-2070.
2. Basch, E. Toward a Patient-Centered Value Framework in Oncology.JAMA 315.19 (2016): 2073-2074.
3. Porter M. What Is Value in Health Care?. N Engl J Med 2010; 363:2477-2481.
4. Magnuson A, Dale W, Mohile S. Models of Care in Geriatric Oncology. Curr Geriatr Rep. 2014 Sep; 3(3): 182–189.
5. Mc Cartney M, Treadwell J, Maskrey N, Lehman R. Making evidence based medicine work for individual patients. BMJ 2016; 353: i2452


Monday, 6 November 2017

Precision medicine in the elderly care


Marco Inzitari


One of the challenges launched by President Barack Obama ($215 million for 2016) is the "Precision Medicine Initiative" a concept that goes against the treatment focused on the "average-patient". According to this initiative, as a first step, cancer treatments should be oriented to the specific genetics of the patient. For this reason, we often refer to the future of oncology as a "precision medicine". As another example, to continue with oncology, the Watson Intelligent System (IBM) will provide support to oncologists for informed and well fitted decision-making, analyzing patients' medical records and looking for possible evidence-based options.

Monday, 30 October 2017

Prediabetes epidemic in sight








Prediabetes is a terminology that, recently, is used when a person is detected with higher than normal levels of blood glucose, but there is no pathology. Prediabetes could be understood as a disposition to develop diabetes in the future, a disease that, in turn, represents a condition that puts one at risk of serious affections such as nephropathy, retinopathy or cardiovascular disorders, among others. Due to this chain of risks, and with a healthy intention to reduce morbidity and mortality, the American Diabetes Association (ADA) led a study to consider that glycosylated haemoglobin (HbA1c) is a test that can be done without any preparation or need for fasting and see if it can become a new criterion for detecting prediabetes. The concern arises when, according to this diagnostic extension, it’s estimated that in millions of pre-diabetics would show up: in China 493, in the US 86 and in Spain 6, to cite three countries from which I have data.

Monday, 23 October 2017

The Patient Revolution according to Victor Montori








In 2016, Victor Montori, a professor of medicine and diabetes doctor at the Mayo Clinic, launched The Patient Revolution, a foundation whose mission is to help make truly patient-centred treatment a reality. In his new book, Why We Revolt, Montori argues that “industrial medicine” has corrupted the mission of medicine to the point where doctors are now incapable of caring for the people who place their trust in them (for further information about the author in this same blog, search for “Montori, V." entries in the tags [top-right-hand column].

Monday, 16 October 2017

The face as a mirror... of the pocket!

Pedro Rey


As this is my first post on this blog, let me introduce myself. I am a researcher into behavioural economics, a field that uses ideas from psychology to enrich the study of economic problems. More specifically, at present we are working on a project that – as I will explain at the end of this piece, and for various reasons – may have interesting implications in the field of medicine.

Our research aims to answer a simple question: what is the relationship between how much consumers like the products they buy and how much they are willing to pay for them?

Monday, 9 October 2017

An extensive model for complex chronic patients








The emergent phenomenon of multi-chronicity and geriatric fragility is analyzed from all points of view: demographic, epidemiological, the use of resources and the economic impact, to mention only the most outstanding. Now familiar with the tendency, we’re facing the challenge of finding out how to provide appropriate services to patients who, due to the precariousness of their health, or their social circumstances, or both, suffer instability and become frequent and directionless visitors.

This group of complex patients, although not too large, is stressing the rigidities of health systems in three ways: a) the saturation of hospital emergency services consuming ambulances and observation beds is unable to give effective responses to the needs of these people, b) lack of coordination of transfers between levels, especially between the hospital and primary care, and c) poly-medication due to prescription fragmentation.

Monday, 2 October 2017

What do chronic patients want?








Fragmentation of services is a disgrace for complex chronic patients, for people with combined health and social needs, for fragile people and, in short, for the elderly population. Hence, most governments are engaged in service integration initiatives, but progress is slow and the results are disappointing because systems are too fragmented: in budgets, in access rights, in circuits, in professional cultures, in institutions, in public and private providers, etc. However, the British have proposed a merger of services by 2020, and since they recognize that, as things stand, offering people-centred care will be a bulky process, in the summer of 2013 they launched a project, “People helping people", a project that is ambitious in vision but modest in methodology and budget.

What is "People helping people"?

The program is working on 25 pilot areas that volunteered to test (as previously done in Torbay) different ways of coordinating and integrating services in order to promote patient-centred care, for which they rely on a single operative objective of elaborating, on the part of all the actors, of individualized plans that adapt to each person’s particular needs and way of life. In terms of methodology, the project has adopted the "triple aim" (Institute for Healthcare Improvement), which develops the following principles: a) improve patient experience, b) improve the health and well-being of the population, and c) reduce the waste and, therefore, the cost per capita.