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car-t. hype or hope

a few weeks ago, I attended the canadian agency for drugs and technologies in health [CADTH] symposium in edmonton, AB. the opening plenary discussion was on ‘the hope and hype’ in healthcare. your perspective on this, of course, depends on how you’re looking at therapies, technologies and devices.

a health economist may look at immunotherapies used to treat melanoma, for example, and say that it’s all hype because only 30% of patients respond to treatment, while a clinician, on the other hand, might see it differently because where previously he was losing a large majority of his patients with chemotherapy, he is now seeing a therapy that is effectively treating 30% of his patients. and these patients are eventually living with no evidence of disease [NED-because everyone is too afraid to say cured]. these are the types decisions that payors and decision makers need to grapple with— measuring cost and effectiveness of therapies and the value they bring to cancer and patients with the financial and sustainability constraints of our healthcare systems. 

enter car t-cell therapy. in 2018 ASCO heralded chimeric antigen receptor t-cell [car t-cell] therapy as the advance of the year, ushering in a new era of novel hematological cancer treatments. it’s important to highlight that this therapy, is currently only being used in the real world in the last resort treatment of some blood cancers. this means a marginal patient population. studies are currently underway to test the effectiveness in solid tumours, if successful this would exponentially increase the number of patients eligible to receive car t-cell therapy.

so when we have to work within the restraints of cancer drug budgets, capacity resources and infrastructure though- is it all just hype or hope?

frederic rupprecht, wwvp, health economics and market access, johnson & johnson said during that plenary session that “there is no place in healthcare for hype.” and that really struck a chord with me. so while car t-cell therapy is a great advance for hematologic cancers it also comes with sticker shock price tag and is currently the most expensive therapy we have ever seen in cancer care. the one-time infusion requires pre- and post-clinical care and because the treatment is currently only available in two provinces, we also need to take into consideration the out of pocket costs and non-treatment related expenses that are not included in the drug price tag. 

with all this in mind, we can’t deny the responses that patients have had to car-t cell therapy. for some who are only at the beginning of it- and who will potentially contribute to society, economically and socially for decades- creating an ROI that is priceless. and for others who are at the end of theirs but who have already given their fiscal and social contributions.  

so the question for me is not, ‘does cost outweigh the value’, or even ‘if it’s hype vs hope’, but rather how can we identify patients who are high-risk before they relapse and how can we get it to patients earlier in their treatment pathway and create even more value for car t-cell therapy for these patients.


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