Rationing in urologic oncology: lessons from sipuleucel-T for advanced prostate cancer

Engaging patients in complex clinical decision-making: Successes, pitfalls, and future directions

BACKGROUND

By 2022, there will be 18 million predicted cancer survivors, which is an estimated 30% more than the number of survivors in 2012. In prostate cancer alone, the most common cancer in American men other than skin cancer, 1 in 7 men will be diagnosed during their lifetime. Nevertheless, only approximately 1 in 39 will actually die of the disease. Although life expectancy is often good, these men have multiple treatment management options to choose from, including active surveillance, surgery, or radiotherapy, each of which carries its own array of long-term adverse effects. The same applies to renal cancer where patient have to sift through information to decide among active surveillance, partial nephrectomy, racial nephrectomy, robotic vs. open surgery, and ablation.

BASIC PROCEDURES

Ultimately, patient, providers, and stakeholders lack high-quality evidence to effectively guide treatment decisions, and these decisions become even harder to discern when considering end-of-life care, palliative care, and the ethics regarding the new End of Life Option Act. As of November 1, 2016, the number of open urologic cancer clinical trials listed on ClinicalTrials.gov was 843.

MAIN FINDINGS

Although we continue to make tremendous strides in urologic cancer care, our options for choosing the best treatment from a patient and provider standpoint are seemingly growing murkier. We need to continue to understand how health-related quality of life varies from patient to patient, and ultimately, incorporate patient preferences and values into the treatment decision in order to make high-quality treatment decisions.

CONCLUSIONS

The remained of this articles will focus on the significant strides made in urologic oncology regarding these difficult decisions from localized disease to end-of-life care and also will detail what needs to be done as we continue to pivot forward.

Sipuleucel-T (Provenge(®))-Autopsy of an Innovative Paradigm Change in Cancer Treatment: Why a Single-Product Biotech Company Failed to Capitalize on its Breakthrough Invention

Approved by the US Food and Drug Administration (FDA) in 2010, sipuleucel-T (Provenge(®)) was the first 'personalized' cancer vaccine for the treatment of prostate cancer in a metastatic, non-symptomatic population of 30,000 men in the USA. Sipuleucel-T is prepared individually for each patient and infused in three sessions over a period of 1 month. However, in 2015, Dendreon, the owner of sipuleucel-T, filed for bankruptcy. This opinion paper reviews the probable reasons this innovative product failed to achieve commercial success. PubMed and internet searches were performed focused on pricing, reimbursement, and market access. We found that sipuleucel-T's FDA approval was delayed by 3 years, reportedly because of the vaccine's new mechanism of action. Sipuleucel-T was cleared by the European Medicines Agency 2 years later, but other national agencies were not approached. It was priced at $US93,000 for a course of treatment, and this high price combined with the company's late securement of reimbursement for the vaccine by the US Centers for Medicare and Medicaid Services (CMS) resulted in another year's delay in accessing the market. Despite a positive recommendation by the National Comprehensive Cancer Network, sipuleucel-T's complex administration, high price, and uncertainty about the reimbursement status deterred doctors from prescribing the product. Furthermore, the vaccine's supply was limited during the first year of launch due to limited manufacturing capacity. In addition, two oral metastatic prostate cancer drugs with similar survival benefits reached the US market 1 and 2 years after sipuleucel-T. Also, even though Dendreon's market capitalization topped $US7.5 billion following the FDA's approval of sipuleucel-T, this value degraded gradually until the firm's bankruptcy 5 years later. We conclude that the bankruptcy of Dendreon was largely due to the delay in securing FDA approval and CMS coverage, as well as the high cost that had to be incurred by providers up-front. Licensing sipuleucel-T to a pharmaceutical company more experienced in the market access pathway may have saved the company and the product.

Economic evaluation of sipuleucel-T immunotherapy in castration-resistant prostate cancer

The objective is to examine the cost-utility of sipuleucel-T immunotherapy in asymptomatic or minimally symptomatic castration-resistant prostate cancer patients. The addition of sipuleucel-T immunotherapy to standard treatment led to a gain of 0.37 quality-adjusted life-year (QALY) at an additional cost of US$104,536. The incremental cost-utility ratio was US$283,000 per QALY saved. Threshold sensitivity analyses indicated that a price reduction of at least 53%, or application in a group of patients resulting in the relative reduction in the mortality rate of at least 39%, ought to augment the economic value of this regimen. Sipuleucel-T immunotherapy treatment at the current price with 96.5% certainty is not cost-effective. The specific group of patients who will benefit more from the treatment should be revealed and treated, or the cost of the vaccine should be lowered significantly to increase its economic value. Accounting for crossover treatment in control patients improves sipuleucel-T's value (US$132,000 per QALY saved) although further investigation is necessary.

Does comparative effectiveness research promote rationing of cancer care?

Comparative effectiveness research aims to inform health-care decisions by patients, clinicians, and policy makers. However, questions related to what information is relevant, and how to view the relative attributes of alternative interventions have political, social, and medical considerations. In particular, questions about whether cost is a relevant factor, and whether cost-effectiveness is a desirable or necessary component of such research, have become increasingly controversial as the area has gained prominence. Debate has emerged about whether comparative effectiveness research promotes rationing of cancer care. At the heart of this debate are questions related to the role and limits of patient autonomy, physician discretion in health-care decision making, and the nature of scientific knowledge as an objective good. In this article, we examine the role of comparative effectiveness research in the USA, UK, Canada, and other health-care systems, and the relation between research and policy. As we show, all health systems struggle to balance access to cancer care and control of costs; comparative effectiveness data can clarify choices, but does not itself determine policy or promote rationing of care.

Ethical considerations for the clinical oncologist in an era of oncology drug shortages

Shortages of injectable drugs affect many cancer patients and providers in the U.S. today. Scholars and policymakers have recently begun to devote increased attention to these issues, but only a few tangible resources exist to guide clinical oncologists in developing strategies for dealing with drug shortages on a recurring basis. This article discusses existing information from the scholarly literature, policy analyses, and other relevant sources and seeks to provide practical ethical guidance to the broad audience of oncology professionals who are increasingly confronted with such cases in their practice. We begin by providing a brief overview of the history, causes, and regulatory context of oncology drug shortages in the U.S., followed by a discussion of ethical frameworks that have been proposed in this setting. We conclude with practical recommendations for ethical professional behavior in these increasingly common and challenging situations.

The changing landscape in the treatment of metastatic castration-resistant prostate cancer

The past few years have brought increasing advances in the therapeutic management of metastatic castration-resistant prostate cancer with the approval of several agents, including vaccine therapy with sipuleucel-T, second-line chemotherapy with cabazitaxel, the bone-targeted pharmaceutical denosumab, and the novel antiandrogen therapy abiraterone acetate. There are ongoing developments with other agents in the pipeline such as MDV3100 and alpharadin that have shown promising results. This review describes the clinical trials that brought about the drug approvals of various agents and offers some insights regarding a rational approach to optimal treatment sequencing for these drugs since national guidelines are currently lacking.

Core elements of the patient protection and affordable care act and their relevance to the delivery of high-quality cancer care

The Affordable Care Act (ACA) contains many provisions that affect cancer care. The provisions of health care reform aim to improve access to quality cancer care, particularly among the most vulnerable Americans. However, health care reform also offers many challenges and opportunities that affect every stakeholder in oncology. This article summarizes the ACA provisions relevant to oncology, discusses the ethical implications for the oncology caregiver, and describes the effects on specific oncology stakeholders.