Can these people do logic?

Karol Sikora is an extremely eminent man. Clearly bright. But somewhat lacking in logic:

The fact that the populations of the Western world are ageing, together with our increasingly unhealthy lifestyles, is dramatically increasing the incidence of cancer.

If we are all living longer then we do not have increasingly unhealthy lifestyles. Increasingly unhealthy lifestyles would show up in our all living fewer, not more, years.

This is just simple, basic, logic.

The other more basic problem is that when discussing the costs of the new cancer drugs no one seems to be looking at the patent system.

No, I don\’t mean whether this is the right way to research or pay for the research into new drugs. Rather, that by definition, these new drugs are not going to be expensive forever. It isn\’t some huge cost that is forever going to rise: it\’s a bolus of costs passing through the system, like a pig through a snake.

Because patents run out, the development costs (those hundreds of millions on the Phase III trials mostly) have been paid…..or not paid for an unsuccessful drug but that\’s Big Pharma\’s problem…..and these drugs now out of patent can be priced at or around their average production cost, not above their sunk cost.

The drug which is patented today becomes cheap in 17 years time. The drug which is approved today after trials is likely to be cheap in 10 years time (yes, patents run from time of patent, not time of approval). Herceptin comes off patent in 2015 or so: so all our arguments about the high cost per month of life gained change around and about then.

The same is true of all these other expensive drugs.

Someone, somewhere, whether through patents, direct taxpayer subsidy, auctions, prizes, whatever, needs to pay these development costs. Once they\’re paid all of these treatments are going to get a lot cheaper which really does change all of the calculations that we\’re making.

And what annoys me is that this basic fact doesn\’t seem to enter into the public conversation.

Herceptin may or may not become as cheap as aspirin: but it sure as hell ain\’t gonna stay at $100,000 per treatment per year.

16 comments on “Can these people do logic?

  1. > If we are all living longer then we do not have increasingly unhealthy lifestyles… This is just simple, basic, logic.

    No it isn’t. An alternative hypothesis would be better fixups, ie medicine. You need actual evidence to decide between the two, or even if the two had competing effects, not logic. And no, you can’t wrap better medicine as part of “lifestyle”. In fact I’m not sure you can even wrap sanitation up in lifestyle.

    *That* is simple, basic logic :-)

  2. There is then a very simple solution – have the NHS refuse to buy any drugs still under patent.

    It’s already stuck in a 1950s nanny-state-knows-best, accept-what-you’re-given, producer interest time warp, so I doubt anyone would notice anyway. And we could also as a result disband the NICE (doubleplusgood newspeak acronym there!) committee, as they would no longer have to deny all the expensive treatments to English patients.

  3. I havemy professional interest to declare on this topic, but there are three further things:

    1: Longer patents might actually lower drug costs (at least initially). It seems very odd that a billion dollars of investment to improve human health enjoys substantially less IP protection than Cliff Richard gets. (This also suggests that Cliff Richard has better lobbyists than evil big pharma).

    2: A lot of that cost, mostly for the biologicals, isn’t ever going to go away, because they really are bloody expensive to make, even once you’ve amortized the development costs.

    3: Totally contrary to my interest, we desperately need to have an adult, global conversation on whether $100,000 to extend one lifespan by 3-6 weeks is the best use of that resource. Ever suggesting you shouldn’t do it gets you called an evil money-obsessed whatever, after all, life is priceless and how dare you turn someone down the chance to extend it. Money is just money, innit?

  4. JamesV, a lot of that cost is most definitely going to go away as Tim suggests – take imatinib (glivec), a wonder drug of the early 21st century. That’s a £20K+ p.a cost that will come down to about £200 p.a when it is off patent in 2 years time. You may well be right about the biologics but that’s why they could remain a minority treatment. If herceptin remains an expensive biologic, it’s small molecule counterpart lapatinib will be off patent in the 2020′s and that will be a cheap.

  5. Snarks:

    1. Unhealthy is not precisely the same as “reduces life expectancy”. I suppose the moderately evil if necessary (presuming a bureaucratic approach) QALY does try to correct for this. To take an extreme viewpoint – a lifestyle which resulted in paraplegia (or coma) at 17 without affecting your life expectancy could accurately be described as unhealthy.

    2. “Ageing population” does not require longer live expectancy. A reduced birth-rate will do it quite happily.

    3. Nor does your logic factor in improvements in general environment or treatment of non-fatal effects (i.e. an individual may lead a less healthy life than his grandfather did, yet have a greater life expectancy.) This may be logically equivalent (it is certainly logically similar) to snark 1.

  6. we desperately need to have an adult, global conversation on whether $100,000 to extend one lifespan by 3-6 weeks is the best use of that resource. Ever suggesting you shouldn’t do it gets you called an evil money-obsessed whatever, after all, life is priceless and how dare you turn someone down the chance to extend it.

    This, to the power of a million. However, the average punter is a tit like Arnald, who fits exactly with the stereotype you’ve outlined, so ain’t gonna happen.

  7. john b
    Are you saying that I think that a life, whatever tenuous situation it’s in, should benefit from cash intensive drugs because the drug exists, when the same amount could prolong more lives with less cash intensive issues?

    Or the opposite?

    I’m either reading too much sarcasm in the original, or not enough.

    Isn’t that what NICE do? Isn’t that what the US call the death panels etc?

  8. I also thought I read somewhere that Cancer is a disease of old age…ergo the longer we live and survive all the other stuff that used to kill us off, the more likely that Cancer is the one that gets us in the end.

  9. @John B,

    The evil bastard neoliberal capitalist approach is to let those who feel the huge expense worth it (and that will admittedly be a lot of people as you can’t take your money with you) pay for it themselves, but take this kind of thing out of the remit of publicly-funded healthcare.

  10. @ James V: You’ve exactly described the current system. If the medical treatment you want is not available on the NHS, there’s nothing to stop you paying for it yourself.

    Also, although I agree with your sentiment that it would be good to have an adult debate about the most effective use of financial resource, I doubt whether that’s really possible in open forum. If I’m dying of cancer today, and my life would be extended by a costly drug, I’m not likely to be impressed by being told that it’s all OK really because the drug will get cheaper in a few years time after the patent expires. Or should that be after the patient expires?

    Thank goodness for NICE, say I.

  11. Tim

    “If we are all living longer then we do not have increasingly unhealthy lifestyles. Increasingly unhealthy lifestyles would show up in our all living fewer, not more, years.

    This is just simple, basic, logic.”

    Leaving aside that mortality and morbidity are not the same thing, I’m afraid you don’t understand what logic is. Logic tells us nothing about the world: it is concerned only with the formal relationship between propositions. A false proposition can be validly derived from false propositions.

  12. Churm R. (nice nod to Beachcomber and Pratchett, BTW): “If the medical treatment you want is not available on the NHS, there’s nothing to stop you paying for it yourself. ”

    Ah, but there is*. There were proposals to allow “top-up” care but as far as I know they were never enacted. You cannot separate NHS from private provision. Buy your chemo drugs yourself and you are deemed to have gone fully private, so no more NHS for you. For example. 2008, but I don’t think there’s been any policy change.

    * unless things have changed recently and I missed this, in which case retract the above.

  13. @David Gillies: The guidelines (for England) were revised in 2009 shortly after your source report, and explicitly state: “NHS organisations should not withdraw NHS care simply because a patient chooses to buy additional private care…the NHS should continue to provide free of charge all care that the patient would have been entitled to had he or she not chosen to have additional private care.” It’s still a thorny issue in practice, though.

  14. There was a reasonable grown up debate on Today involving the Prof who has written this written this report: http://www.bbc.co.uk/news/health-15032862

    and it included a couple of people who have used these expensive drugs.

    One of the innovations he did mention was a move to success based payments for some cancer drugs. Apparently the problem with a lot of new drugs is that the success rate is something like 1:100.

  15. JamesV – “1: Longer patents might actually lower drug costs (at least initially). It seems very odd that a billion dollars of investment to improve human health enjoys substantially less IP protection than Cliff Richard gets. (This also suggests that Cliff Richard has better lobbyists than evil big pharma).”

    It is absurd that Cliff Richard deserves more reward for his songs than someone working to cure cancer. So I am with you there. A faster regulatory process might help too.

    “2: A lot of that cost, mostly for the biologicals, isn’t ever going to go away, because they really are bloody expensive to make, even once you’ve amortized the development costs.”

    For biologicals. But the costs of bringing drugs to market are measured in billions mainly due to the regulatory hoops they have to jump through. A lot of that cost could be reduced but the price would be a greater risk of another Thalidomide. I think that would be worth it myself, but then I might be a tad heartless.

    “3: Totally contrary to my interest, we desperately need to have an adult, global conversation on whether $100,000 to extend one lifespan by 3-6 weeks is the best use of that resource. Ever suggesting you shouldn’t do it gets you called an evil money-obsessed whatever, after all, life is priceless and how dare you turn someone down the chance to extend it. Money is just money, innit?”

    Which is why we have NICE to do that for us. But the nasty conversation would be to say that we have enough regulation, we actually have too much, and it is impeding research. We need less – even at the risk of another scandal like Thalidomide. Great breakthroughs were not created in large multinational corporation’s labs. They were isolated scientists doing what interested them. Often grossly unethically. We need to make that possible again.

    Because we are running out of new drugs and it is likely that the industry will shut down. It has already more or less stopped making drugs for actual sick people and concentrated on the worried well.

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