A Survey of Battlefields in the War on Cancer: Oncologists Reporting from the Front Lines

In 2008, we launched an oncology market surveillance program, “Oncologists Look at Oncology: Prognosis for U.S. Cancer Care.” We were moved to do this by what we were hearing from oncologists as we conducted in-depth interviews with them on behalf of our clients. Our clients in the field, who range from small startups to leading “Big Pharma” companies, shepherd innovative molecules from the bench to the clinic and, if successful, to the commercial marketplace. But over 35 years after the “War on Cancer” was famously declared by President Nixon in 1971, what we were hearing from oncologists on the front lines of cancer care was a sense of frustration, even despair.

A significant part of oncologists’ frustration at the time was financial. In 2006, Medicare and Medicaid reimbursement to physicians for in-office intravenous cancer medications was cut dramatically. Private practice oncologists had been earning 50 percent or more of their total personal income from profits on IV medication -- profits earned directly from reimbursement paid by public and private payers. The industry published fictional “average wholesale prices” (AWP) that set the reimbursement physicians would receive, but physicians were able to purchase drugs at prices substantially below AWP. Centers for Medicare and Medicaid Services’ updated reimbursement policy based on actual average selling prices rationalized reimbursement but changed the game for oncologists.

But loss of personal income wasn’t the only thing that seemed to have disheartened oncologists. They told us that they were sending more patients to hospitals for drug administration when coverage was uncertain -- even though patients generally feel more comfortable receiving treatment in familiar, less institutional treatment settings -- because private practices could no longer absorb unreimbursed drug costs. They told us that they were unable to treat patients with the best available care because of patients’ inability to afford requisite out-of-pocket co-payments. They told us that they did not see how providers or patients or payers could keep pace with the escalating costs of new cancer therapies. They told us that their colleagues were retiring and their children were pursuing specialties other than oncology because both financial compensation and lifestyle were better in procedure-oriented fields.

The New “Political” Science: Avastin Breast Cancer Debate Exposes Paradox and Contradictions

The FDA’s recommendation to rescind Avastin’s metastatic breast cancer indication provoked a mix of commentary, commendations, and outcry from across the spectrum of stakeholders with an interest in the decision – and in what the decision might mean for the future: the future of cancer therapy approvals, evidence-based medicine, coverage for off-label use, drug pricing, and healthcare rationing … among other things.

This debate lies at the center of a tangled web of science, psychology, politics, economics, and ethics. Science and psychology, in particular, collide here in a way that reminds us of the challenge of selling the public on evidence-based medicine.

We are built by evolution to see cause-and-effect. The subset of women with metastatic breast cancer who have done well on Avastin almost cannot help but believe that they have done well because of Avastin. And it is no easy thing to overcome this built-in visceral conviction with the dry logic of rationality or the weight of evidence from patients treated in groups rather than as individuals.