Prostate Cancer, Pediatrics, and Priorities

America has the best health care that money can buy, but there is not enough money. Is it reasonable to have our nation pay for sipuleucel-T (Provenge), a $10,000/month medication that will prolong the life of a Medicare patient with widespread metastatic prostate cancer by maybe 4 months and yet not have the money to immunize children? For example, availability of a vaccine (palivizumab [Synagis]) to prevent respiratory syncytial virus in children is severely restricted, although it is proven to prevent a potentially life-threatening pulmonary infection.

The estimated cost is $10,000 per child for 5 months of the cold season. Is it reasonable to have a national policy that any medication approved by the FDA is also paid for with public funds? Perhaps, but there are consequences.

Sipuleucel-T is not only a new treatment; it has become an example of advancement of science without regard to the economics of medicine. It is a metaphor for possible

misappropriation of limited resources and priorities.

Should we have an open discussion about the ramifications of balancing the budget on the back of health care? When members of Congress vote against suspending the sustainable growth rate (SGR) due to the cost, are they willing to say that they are for prioritizing or rationing care?

Some of the politicians who recently railed against “death panels”—something that was never proposed—are the same ones who have rallied crowds around the belief that the debt is unsustainable and that there must be control of the budget. For those politicians who want to eliminate the SGR and thus not reduce money going to health care, are they willing to say that the $250 billion (and growing) cost of not implementing the SGR is not a concern to the economy? Is the national debt and voracious borrowing from China acceptable?

The nation cannot have it both ways. The reason why there is such contention is that these are very tough choices. The American way of solving the healthcare crisis should be to prevent, diagnose early (using advanced biomarkers), and cure our way out of the problem.  This would reduce costs, democratize healthcare by having cures (inherently much cheaper than prolonged treatments) available to all, and solve the fundamental issue—that the cause of the healthcare crisis is the cost. It has been estimated that if

medical science could push back the onset of Alzheimer’s disease by 5 years (not even

prevent it), the Medicaid crisis would be resolved because Medicaid nursing homes

would be emptied.

Where the Money Is

When asked why he robbed banks, Willie Sutton reputedly said, “Because that’s where the money is!” Two other adages—“Show me the money,” from the movie Jerry McGuire, and “If they say it’s ‘not the money,’ you know it is the money”— are also instructive when it comes to the cost crisis in health care. There are only a few places in the U.S. economy that, if reduced, will make a real difference in the debt. Medicare and Medicaid make up 20% of the budget today. In 2050, they will consume 40%. If Americans are unwilling to solve the entitlement problem, the country will eventually be bankrupt, and even China will not be able to buy us out of it.

There must be consistency in our thinking.

Sipuleucel-T is a potentially valuable medication to a subpopulation of patients with metastatic prostate cancer refractory to hormones, for whom other chemotherapies

have probably failed. These unfortunate individuals will gain an average of 4 months of life, although the quality of extended life might not be very satisfying. If

budgets are ever to be balanced, this questionable benefit would likely result in others

not being treated.

So let us have a real debate about the cost of health care and the choices (including

sacrifices) that need to be made to pay for it. Health-care economics must

be viewed not in a vacuum, but rather, in a fiscal universe of choices and limitations.

Let our priorities dictate that when there are limited funds, the children are first to receive the care they richly deserve. And finally, we should focus on applications and translational research that will bring prevention, early diagnosis, and cure to patients, thereby eliminating prolonged, costly, chronic treatments.