Glioblastoma, Avastin, and cost of cancer drugs

Cancer Drugs Bring Cost-of-Life Decisions
Following is a(n impossibly long) link to an article that appeared in the September 27 edition of The Oregonian by AP writer Marilynn Marchione, "Cancer drugs bring cost-of-life decisions." Some excerpts: "For the past decade, new cancer-fighting drugs have topped $5,000 a month. Only a few of these keep cancer in remission so long that they are, in effect, cures. For most people, the drugs may buy a few months or years. Insurers usually pay if Medicare pays.... Medicare usually pays if the federal Food and Drug Administration (FDA) has approved the use.... When is a drug considered cost-effective? The most widely quoted figure is $50,000 for a year of life.... Higher costs seem to be more accepted for cancer treatment than for other illnesses, but there's no rule on how much is too much."

http://news.yahoo.com/s/ap/20100927/ap_on_he_me/us_med_costly_cancer_drugs;_ylt=Avsk6pTag662ngRCGc3GgBas0NUE;_ylu=X3oDMTN2bDM3N2hvBGFzc2V0A2FwLzIwMTAwOTI3L3VzX21lZF9jb3N0bHlfY2FuY2VyX2RydWdzBGNjb2RlA21vc3Rwb3B1bGFyBGNwb3MDMTAEcG9zAzcEcHQDaG9tZV9jb2tlBHNlYwN5bl9oZWFkbGluZV9saXN0BHNsawM5MzAwMGNhbmNlcmQ-

Avastin for Metastatic Breast Cancer
The October 4 issue of Newsweek (p. 50) has an interesting article about Avastin and its use specifically in metastatic breast cancer (Begley S. It's not about rationing: why the FDA may reverse course on Avastin.) In the U.S., Avastin (bevacizumab) is approved for treatment of metastatic colorectal cancer, non-squamous non-small cell lung cancer, metastatic breast cancer (MBC), glioblastoma (that's me), and metastatic renal cell carcinoma. In 2008 FDA gave "fast track" approval for Avastin in MBC, conditional on the manufacturer (Genentech) running additional clinical trials of the drug's safety and efficacy. Turns out that not only did Avastin not keep women with MBC alive, but it seems as if the drug's toxicity cancels out any benefit. These dismal results are what led an FDA panel to vote 12-1 in July to rescind the conditional approval of Avastin for MBC. A decision by the FDA is expected by year's end. Of course there are stories galore of women with MBC who claim to be alive because of Avastin. There are always patients who live longer than average; they attribute it to the treatment. That some women did live longer on Avastin may simply reflect the natural heterogeneity of the disease and say nothing about the therapy.

Avastin for Glioblastoma (Moen MD. Bevacizumab: in previously treated glioblastoma. Drugs 2010;70:181-9)
Glioblastomas are malignant primary brain tumors. They are the most common type of gliomas, and account for 18.5% of all primary brain and CNS tumors. Standard treatments for glioblastoma include surgical removal of as much of the tumor as possible (check), postoperative radiotherapy (check), and chemotherapy with temozolomide (check). The prognosis for patients with glioblastoma is poor, with an estimated 5-year survival rate of 3.4%. Glioblastomas are particularly aggressive, and are associated with rapid growth and angiogenesis (blood vessel growth); the formation of new blood vessels is essential for tumor development.

I started bevacizumab (Avastin) yesterday. Bevacizumab is a recombinant humanized monoclonal antibody that binds to human vascular endothelial growth factor (VEGF) and inhibits angiogenesis and hence tumor growth. Bevacizumab was approved by the FDA in May 2009 as a single agent for the treatment of glioblastoma with progressive disease following prior therapy. It is administered as an intravenous (IV) infusion over 30 minutes. The recommended dose for treatment of glioblastoma is 10 mg/kg every 2 weeks. Patients should continue treatment until disease progression or unacceptable toxicity. Given the nature of the disease, bevacizumab was generally well tolerated in clinical trials.

A word about cost and effectiveness of Avastin for glioblastoma: At my dose, the cost of a single infusion is north of $4500, or about $118,000 a year, though few patients live that long. The effectiveness of Avastin in glioblastoma is based on an improvement in objective response rate. There are no data demonstrating an improvement in disease-related symptoms or increased survival with Avastin. Yet treatment with temozolomide and bevacizumab are the standard of care today for treatment of glioblastoma. I failed the former and am on the latter.

My intent is not to paint an overly morbid or pessimistic picture about my situation. I feel pretty good, and I have a lot to be thankful for. But on the other hand, I do need to be realistic (while cautiously optimistic) about where we stand. Count my blessings, and take one day at a time. By the way, I am now 10 months out from my diagnosis on Thanksgiving 2009.