The Unsustainable Economics of Cancer Drugs

In New York magazine, Steve Hall lays out the good, bad, and the ugly of cancer-drug economics. Warning: it is mostly bad and ugly.

The pharmacist e-mailed the numbers, and Saltz stared at the figures on his computer screen. Zaltrap, the drug that was extremely similar to Avastin, cost roughly $11,000 a month. (And because that extra 42 days wouldn’t be possible without taking the drug for, say, seven months before—which was roughly what was happening in clinical trials—the price for that six-week life extension could be as high as $75,000.)

“Wow,” he said to himself, “that’s a deal-changer for me.”

That may not seem like a heretical statement, but the unspoken rule in American health care is that doctors should never consider the cost of a medicine that might be beneficial to patients. When the FDA approves a new cancer drug, it analyzes safety and effectiveness only. Medicare is obliged to reimburse payment for the drug, and private insurers in most states must cover the cost. Any doctor who considers cost—or the value of a costly drug—risks being accused of “rationing” health care.

Beer for Babies and the Tapeworm Diet

In our podcast “100 Ways to Fight Obesity," Steve Levitt and David Laibson discuss the possibility of using tapeworms to fight weight gain. (Seriously.) That prompted a reader named Scott Genevish to send us a real-seeming (?) old advertisement for "Sanitized Tapeworms, Jar Packed" (below). It was accompanied by a bunch of other old ads that are all, from the perspective of 2013, radically outdated for one reason or another. I have no idea if all the ads are real; I'm sure most of them have made the online rounds before. Still, it might be worth a look -- especially when you think about how the line between repugnant and not repugnant can shift over time, sometimes faster and more dramatically than you'd ever predict.

"Under the Medical Tent at the Boston Marathon"

That is the title of an essay by Sushrut Jangi, in the New England Journal of Medicine:

Suddenly, there was a loud, sickening blast. My ears were ringing, and then — a long pause. Everyone in the tent stopped and looked up. A dehydrated woman grabbed my wrist. “What was that?” she cried. “Don't leave.” I didn't move. John Andersen, a medical coordinator, took the microphone. “Everybody stay with your patients,” he said, “and stay calm.” Then we smelled smoke — a dense stench of sulfur — and heard a second explosion, farther off but no less frightening. Despite the patient's plea, I walked out the back of the tent and saw a crowd running from a cloud of smoke billowing around the finish line. “There are bombs,” a woman whispered. My hands began to shake. ...

At the tent, I stood in a crowd of doctors, awaiting victims, feeling choked by the smoke drifting along Boylston. Through the haze, the stretchers arrived; when I saw the first of the wounded, I was overwhelmed with nausea. An injured woman — I couldn't tell whether she was conscious — lay on the stretcher, her legs entirely blown off. Blood poured out of the arteries of her torso; I saw shredded arteries, veins, ragged tissue and muscle. Nothing had prepared me for the raw physicality of such unnatural violence. During residency I had seen misery, but until that moment I hadn't understood how deeply a human being could suffer; I'd always been shielded from the severe anguish that is all too common in many parts of the world.

FREAK-est Links

1. First-year medical residents made more mistakes when they were required to work fewer hours.

2. Automated education: EdX offers classes online, marks essays and tests.

3. Telemedicine has doctors in Texas treating patients in Antarctica.

4. The history of capitalism is all the rage in history departments.

5. More Nutella thieving: this time it's not Columbia University students.

What If Your Future Had Been Decided By Someone Else's Coin Toss?

From a reader we'll call O.X.H.:

I listened to your podcast on letting a coin decide your future - and wanted to make my own, small contribution to your piece. I am an attending physician now - but back when I was in medical school (early 2000s), I helped out with the admissions process by interviewing prospective candidates. On one day of interviews, my faculty colleague and I conducted six interviews - and by the end of the day, our job was to rank each of the candidates that we had interviewed. We independently agreed on No. 1 and No. 2 (and No. 5 and No. 6), but neither of us could decide between No. 3 and No. 4. He asked me how we should resolve this - and I (jokingly) suggested that we should flip a coin. Ironically, he loved the idea - and pulled out a coin, and then we assigned each candidate to heads/tails. We said that whoever won the coin toss would get 3rd. (Interestingly, we flipped the coin only once - not two out of three.)

Neighborhood, Race, and CPR

An New England Journal of Medicine article looks at the probability of a bystander performing CPR based on neighborhood characteristics including income and race:

Among 14,225 patients with cardiac arrest, bystander-initiated CPR was provided to 4068 (28.6%). As compared with patients who had a cardiac arrest in high-income white neighborhoods, those in low-income black neighborhoods were less likely to receive bystander-initiated CPR (odds ratio, 0.49; 95% confidence interval [CI], 0.41 to 0.58). The same was true of patients with cardiac arrest in neighborhoods characterized as low-income white (odds ratio, 0.65; 95% CI, 0.51 to 0.82), low-income integrated (odds ratio, 0.62; 95% CI, 0.56 to 0.70), and high-income black (odds ratio, 0.77; 95% CI, 0.68 to 0.86). The odds ratio for bystander-initiated CPR in high-income integrated neighborhoods (1.03; 95% CI, 0.64 to 1.65) was similar to that for high-income white neighborhoods.

Penicillin as an Aphrodisiac?

An interesting new paper (abstract; PDF) by the Emory economist Andrew M. Francis explores penicillin's role in shaping modern sexuality:

It was not until 1943, amid world war, that penicillin was found to be an effective treatment for syphilis. This study investigated the hypothesis that a decrease in the cost of syphilis due to penicillin spurred an increase in risky non-traditional sex. Using nationally comprehensive vital statistics, this study found evidence that the era of modern sexuality originated in the mid to late 1950s. Measures of risky non-traditional sexual behavior began to rise during this period. These trends appeared to coincide with the collapse of the syphilis epidemic. Syphilis incidence reached an all-time low in 1957 and syphilis deaths fell rapidly during the 1940s and early 1950s. Regression analysis demonstrated that most measures of sexual behavior significantly increased immediately following the collapse of syphilis and most measures were significantly associated with the syphilis death rate. Together, the findings supported the notion that the discovery of penicillin decreased the cost of syphilis and thereby played an important role in shaping modern sexuality.

(HT: Marginal Revolution)

When A Daughter Dies

Not too long ago, I wrote about my sister Linda, who passed away this summer.

Nobody could love a daughter more than my father Michael loved Linda. 

My father (who is a doctor) was realistic from the start about what modern medicine might be able to do to save his precious daughter from cancer.  Even with those low expectations, he was shocked at how impotent -- and actually counterproductive -- her interactions with the medical system turned out to be.

Here, in his own words, is my father's poignant account of my sister’s experience with medical care.

Do the Bacteria in Your Gut Also Influence Your Mind?

Last year, we put out a podcast called "The Power of Poop," which looked at the use of fecal transplants (a.k.a. "transpoosions") to treat everything from multiple sclerosis to Parkinson's disease. A fascinating Scientific American article explores how gut bacteria may have even further-reaching functions:

In the past few years scientists have been discovering that these microscopic inhabitants of our body may be subtly altering our moods, emotions and perhaps even our personalities. Gut microbiota appear to alter gene activity in the brain and the development of key regions involved in memory and learning. These denizens of our intestines could help explain why psychiatric symptoms vary among individuals, as well as their responses to medications. Gut microbes could also account for some of the differences in mood, personality and thought processes that occur within and among individuals.

(HT: Market Design)

The Olympics and the Doctors

A New England Journal of Medicine article explores the history of the Olympic Games as an object of "medical scrutiny," with some interesting highlights:

Physicians have been interested in the Olympics for many reasons. In the 1920s, they probed the limits of human physiology. One group studied the Yale heavyweight rowers who won gold in Paris. An ingenious contraption revealed that at their racing speed — 12 mph — the eight men produced four horsepower, a 20-fold increase over resting metabolism (1925). A 1937 study published in the Journal showed that athletes at the 1936 Berlin games consumed 7300 calories each day (1937).

Of course, physicians are currently most fascinated by the effects and progress of performance-enhancing drugs: