… Finally, there is the inescapable consideration of cost. Most new cancer treatments are very expensive. We may be tempted to remember how expensive the first biological therapy was: When used clinically for the first time, it was transported in armored trucks with police escort. The drug was even recovered from the urine of patients to whom it had been administered because that was less expensive than manufacturing it anew. This drug was penicillin 70 years ago, now cheaper than the glass vials it is sold in. But that is an oversimplification of the likely evolution of anticancer therapy, at least in the short and medium term. The truth is that market forces dramatically influence the way product research is now done.
As a society, we have put the discovery and development of new drugs in the hands of “Big Pharma.” As a result, profitability overrides health benefits. This is painfully obvious when we learn about highly effective drugs that never reach market because the illnesses they alleviate are rare. With tailor-made therapies, this will be an increasingly frequent outcome, as a particular target might be present in only a small fraction of cases. The brutal arithmetic of patient numbers, price and premarketing investment will determine whether a drug is pursued. This calculation may explain the absence of the spectacular cures that were predicted to follow the deciphering of the human genome.
Patients, then, are trapped between profit-driven research and the permanent drive to curtail healthcare expenses. In countries where healthcare services are financed and operated by the state—the prevailing model in many quite capitalistic European nations—a different balance decides whether a drug is approved for use. If the cost of the drug is more than the annual gross domestic product per capita multiplied by the number of years gained, on average, by the treatment, it is not purchased. This might sound like the brainchild of a sinister accountant at the World Bank, but it is also the way decisions are made about life-saving vaccines endorsed by the World Health Organization. In this way, drugs that may spectacularly benefit some patients are not used if the average patient does not respond so dramatically or if the country these patients live in has a low per capita gross product. This policy, in turn, discourages development of new drugs that may be rejected by this decision-making process.
We have the technology and the basic knowledge to embark on the search for individual genes and proteins that are responsible for essentially all types of cancers. This endeavor could enable target therapies that transform deadly tumors into manageable, chronic disease, if not offering outright cures. Such treatments would have to evolve together with precise diagnostic tools, so that tailor-made therapies could be assembled for each patient. But this fantastic perspective may end up crashing into the wall of economic concerns, which are the consequence of marketing health as if it were merchandise.