How much can a cancer patient cost society? New research ensures transparency

They have a cumbersome name and are often the last straw that cancer patients with a particularly aggressive form of blood or lymph node cancer cling to: CAR-T cell therapies. The innovative treatment has been approved for patients for whom all other therapies were powerless. “It represents enormous progress in the fight against cancer,” says oncologist Heinz Läubli, professor and head of the laboratory for cancer immunotherapy at the University Hospital of Basel. “Two years after treatment, half of the patients who previously had no hope are still alive.”

CAR T-cell therapy is a gene therapy that activates the immune system against cancer cells using genetic engineering methods. To do this, the body’s own immune cells, the T cells, are treated so that they can recognize and destroy the out-of-control ulcers.

According to Läubli, the advantage of such therapies, which use the body’s own defenses as an ally, is that they can keep cancer at bay in the long term. “If you don’t catch some cancer cells with chemotherapy, there will almost inevitably be a relapse later. However, with immunotherapies, the immune system remains able to attack in the long term. But that doesn’t necessarily mean they can actually control or even cure the disease in the long term. That remains to be seen.

As spectacular as some of the successes of CAR-T therapy are, the costs of treatment are equally spectacular. According to the list price, a single infusion costs about 370,000 francs; what is actually paid is confidential. “During the first negotiations, the manufacturers justified the high price by saying that there would be hardly any additional costs after the expensive therapy,” says Maria Trottmann, research assistant at health insurer Swica. But that is not true, as appears for the first time from an analysis of nine Swiss health insurers in which Trottmann was involved. The conclusion of the study, which has just been published in the Swiss Medical Journal: CAR-T therapy alone is not enough, there is much more to it.

The study included the treatment costs of eighty patients between the ages of 30 and 84 who suffered from large B-cell lymphoma, a malignant disease of the lymphatic system. Accordingly, the additional costs for cancer patients over the next two years amount to 215,000 francs – significantly more than previous estimates suggested, as Trottmann says.

Oncologist Läubli from Basel is not surprised by the figures: “We are talking about seriously ill patients who need close medical support. You cannot take them home after therapy, but send them to the doctor once a month.”

The disadvantage of the initially uncertain follow-up costs is not a unique feature of CAR-T treatment, but applies to many innovative therapies. “With our research we wanted to create transparency in at least one case. “This is the only way society can objectively discuss how to ensure sustainable financing of the healthcare system in the future,” says Trottmann.

In Switzerland, more than one in five people will develop cancer before the age of 70, which amounts to almost 50,000 new cases per year. There are not many people who benefit from CAR T-cell therapy yet. Also because it is currently only used for malignant blood diseases. This is likely to change in the future as scientists work intensively to develop gene therapy for other types of cancer, such as pancreatic cancer and colon cancer.

This is potentially good news for cancer patients, but: “If prices remain at current levels or even rise further, the healthcare system will face massive cost increases, which will inevitably be reflected in health insurance premiums,” says Trottmann . Medicines, especially new ones, already cause almost a third of the total cost increase. The drugs against cancer and the immune system are the most expensive.

It is not always clear why cancer medicines are so expensive. This is evident from a study led by Kerstin Noëlle Vokinger, professor of law, medicine and technology at the University of Zurich. She explained that cancer drugs are on average about three times more expensive than non-cancer drugs – with no objective explanation for this. In concrete terms, the unjustified additional costs of cancer medicines, the so-called cancer premium, amount to approximately 30,000 francs.

According to Vokinger and her team, a disproportionate share of resources is spent on purchasing cancer drugs. It would therefore be important that price negotiators were aware of cancer premiums and took them into account when negotiating with the pharmaceutical industry, the study said. Then the price could possibly be reduced with good arguments.

The National Ethics Committee in the Field of Human Medicine highlighted the problem of extremely expensive and new drugs in a statement to the Federal Office of Public Health. “Even in a rich country like Switzerland, unlimited financial resources are not available,” said Markus Zimmermann, vice-chairman of the ethics committee and professor at the University of Freiburg. It is therefore clear that not everything that comes onto the market will of course be financed. “If more money is needed for expensive treatments, it should be saved elsewhere, for example in the field of prevention or checks.” In the worst case, this could have negative consequences for the health of the entire population.

For example, following this consideration, between 2014 and 2018, the Federal Office of Public Health (BAG) reimbursed the hepatitis C drug Sovaldi for only a small proportion of people who needed treatment. The reason was that at that time about 40,000 people in Switzerland were infected with the hepatitis C virus. If everyone had been treated, it would have cost health insurers 2.8 billion francs. Too much, the BAG thought.

Because the drug is very cost-effective, the restriction of “Sovaldi” is also controversial from an ethical point of view – as such decisions probably always will be. “It is therefore important that they are democratically legitimized,” says Zimmermann.

In its paper, the Ethics Committee cites the case of Sweden as a positive example: there is an institute there that is responsible for promoting public debate about setting priorities in healthcare. In Switzerland, however, Zimmermann criticizes, not only is there a lack of relevant debates, but there is also no awareness of the necessary restrictions on healthcare.

Britain is one of a few countries to have defined a threshold at which insurable treatments for a quality-adjusted year of life saved typically cap out at between £20,000 and £30,000.

The Federal Court ruled again in 2010 that there was an international upper limit of 100,000 francs per year of life saved, without taking into account the quality of life. In addition, various studies examined the willingness to pay in Switzerland, with the values ​​determined between 100,000 and 250,000 francs per year of life in good health.

However, the political debate on this still needs to be conducted. But this is a sensitive issue that can hardly be discussed objectively in politics, says expert Trottmann: “From the perspective of intergenerational justice, it is necessary to negotiate politically how we as a society can deal with new therapies whose benefits are not certain . and the costs of which are unclear.”