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Special Communication |

Unintended Consequences of Expensive Cancer Therapeutics—The Pursuit of Marginal Indications and a Me-Too Mentality That Stifles Innovation and Creativity The John Conley Lecture

Tito Fojo, MD, PhD1; Sham Mailankody, MD1; Andrew Lo, PhD2
[+] Author Affiliations
1Medical Oncology, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
2Sloan School of Management, Massachusetts Institute of Technology, Cambridge
JAMA Otolaryngol Head Neck Surg. 2014;140(12):1225-1236. doi:10.1001/jamaoto.2014.1570.
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Cancer is expected to continue as a major health and economic problem worldwide. Several factors are contributing to the increasing economic burden imposed by cancer, with the cost of cancer drugs an undeniably important variable. The use of expensive therapies with marginal benefits for their approved indications and for unproven indications is contributing to the rising cost of cancer care. We believe that expensive therapies are stifling progress by (1) encouraging enormous expenditures of time, money, and resources on marginal therapeutic indications and (2) promoting a me-too mentality that is stifling innovation and creativity. The modest gains of Food and Drug Administration–approved therapies and the limited progress against major cancers is evidence of a lowering of the efficacy bar that, together with high drug prices, has inadvertently incentivized the pursuit of marginal outcomes and a me-too mentality evidenced by the duplication of effort and redundant pharmaceutical pipelines. We discuss the economic realities that are driving this process and provide suggestions for radical changes to reengineer our collective cancer ecosystem to achieve better outcomes for society.

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Figure 1.
Graphical Representation of the Results in Table 1: Gains in Progression-Free Survival (PFS) and Overall Survival (OS) for the 71 Drugs Approved by the FDA From 2002 to 2014 for Metastatic and/or Advanced and/or Refractory Solid Tumors

The horizontal lines represent the median values for PFS (A) and OS (B) of 2.5 and 2.1 months, respectively. The oldest approval (imatinib in gastrointestinal stromal tumor, February 1, 2002) is at the left, and the most recent (ceritinib in ALK-positive non–small cell lung cancer, April 29, 2014), at the right. In 3 cases the “gains” were 0 months. In all others where a bar does not appear, it is because for this indication either PFS or OS was not a prespecified end point (or neither was an end point for drugs 29 and 55). Because these were not end points, the values were not reported in the FDA approval announcement and in most cases have also not been published.

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Figure 2.
Comparison of Cancer Therapies in the Pipelines of Pharmaceutical Companies According to Their Putative Mechanisms of Action

For this analysis we began by identifying the top 10 pharmaceutical companies based on 2013 earnings. Because Johnson & Johnson does not provide details of its pipeline, only 9 companies were included in this analysis totaling 168 agents in their oncology pipelines. We defined overlapping as a pharmaceutical agent whose mechanism of action is similar to that of a Food and Drug Administration (FDA)–approved agent and/or that of an agent in the pipeline of another top-10 company. Nonoverlapping was defined as a pharmaceutical agent whose mechanism of action is not similar to that of an FDA-approved drug and also not similar to that of a drug in the pipeline of another top-10 company. However, this does not exclude the possibility that the mechanism is similar to that of a drug in the pipeline of a company that is not in this list. With these somewhat arbitrary definitions, we found that 124 oncology agents (74%) in the pipelines of the 9 companies examined have an overlapping mechanism of action, 41 (24%) have a nonoverlapping mechanism of action, and 3 (2%) have a mechanism of action that is unknown since it is not listed on the company website. The drugs and companies, as well as the assignments, are summarized in the eTable in the Supplement.

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