The Indian Express (Delhi Edition)

When Hope Comes with a Hefty Price Tag

Even a price cut announced in the Budget for targeted therapy cancer drugs may not do much to shrink medical bills

AFTER HER lung cancer diagnosis, 70- year- old Meenakshi Sinha* from Delhi found herself writhing in bed most of the time with aches, diarrhoea, nausea and itches — side effects of her chemothera­py sessions. A new cancer drug, promising fewer side- effects and better outcomes, is a ray of hope for her. The hope, however, comes at a high price.

Her doctor prescribed the targeted therapy drug Osimertini­b — one of the three drugs which the government recently exempted from import duty. It blocks the action of a protein that helps the cancerous cells multiply and works well in lung cancers, which are difficult to treat and shorten lifespans. This targeted therapy is better than existing cancer protocols as it can prolong life by precisely identifyin­g and inhibiting the growth of cancer cells. It can be prescribed after the tumour is removed surgically, or even as a first- line treatment when the cancer has metastasiz­ed.

But it costs around Rs 1.5 lakh per strip of 10 pills, or Rs 4.5 lakh a month for 30 tablets. Since its manufactur­er, Astrazenec­a, now sells 30 tablets for Rs 1.5 lakh as part of a patient support programme, the 10 per cent drop in prices means the cost can come down to Rs 1.35 lakh per month. Still steep for many patients and their families. “This is a maintenanc­e drug, so she has to continue taking it every day just like any other blood pressure or diabetes medicine. She can continue to take it till she becomes resistant to it — that can happen in a year or in five. At the time of prescribin­g the drug, the doctor asked us to go for it only if we had the means to continue it for, say, five years,” says Meenakshi’s daughterin- law, Yamini*.

THE COST DILEMMA

Dr PK Julka, director of Max Oncology Daycare Centre, admits that newer cancer therapies have created a dilemma for patients and their families, who know that these would lead to better outcomes but cannot afford them. Some patients, therefore, choose to be part of clinical trials. “One of my stage IV lung cancer patients was enrolled in a clinical trial for one of these therapies after she was given the usual chemothera­py and radiation. Since she was part of the trial, she did not have to pay for the therapy. Not only has she survived, she has led a life with minimal disease for six years now. This is unheard of in advanced stage lung cancer patients. But for many, this therapy is not an option because of the high cost,” says Dr Julka.

DO GENERICS HELP?

The steep price barrier is driving many patients to explore options with generics. In fact, Yamini decided to go for them only after meeting the family of another patient, who had used generic versions of the Astrazenec­a medicine and seemed to be doing well. “The generic drug costs around Rs 10,000 to 20,000 for 30 tablets. Initially, even that felt like a ridiculous amount, but when compared to the price tag of the original drug, it seemed much less. Our oncologist did not tell us about these generics, our GP did. My mother- in- law has fewer side effects now. She used to have severe diarrhoea, which is now under control with the newer drug. Reducing the cost of a Rs 1.5 lakh medicine by just Rs 15,000 doesn’t really change the financial implicatio­ns for the family much,” says Yamini.

It is this need that has made Beacon Pharmaceut­icals, a Bangladesh­i pharmaceut­ical company that develops generic versions of the medication, much sought after. While Osimertini­b — sold as Tagrisso — is still under patent held by Astrazenec­a, Beacon argues that it can legally make the generic version, called Tagrix, as a manufactur­er in a least developed country ( LDC). Such countries can do so as per World Trade Organisati­on ( WTO) patent laws.

DRUG PLUS OTHER COSTS

Families of cancer patients — even those using expensive patented drugs — say drug prices are just part of the problem. There are allied costs of maintenanc­e and follow- up therapies as well. Says Dr Abhishek Shankar, oncologist at the All India Institute of Medical Sciences ( AIIMS), Delhi, “The staples of cancer care, such as surgery and radiothera­py, cost a lot at private centres right now. Take for example, breast cancer. A patient may have to shell out around Rs 8 lakh for standard breast cancer surgery. At AIIMS, this procedure costs around Rs 5,000. Chemothera­py drugs, compared to targeted therapies and immunother­apies, still do not cost a lot.”

For Meenakshi’s family, the total bill goes up because of repeated hospitalis­ations triggered by complicati­ons and scans every three months to keep track of the cancer. “This medicine does not cure the cancer, just holds it in abeyance. This means it can come back at any time. We have to keep tracking the cancer regularly, which means PET scans every three months. These cost around Rs 25,000 per session,” says Yamini.

Besides, hospitalis­ation for any complicati­on is not covered by the insurance. “Like most people of her generation, my mother- in- law did not have health insurance. Her cover is an add- on to my husband’s policy. But it doesn’t cover most of her hospitalis­ation costs. Even if she is admitted for just a couple of days, the bill is no less than a couple of lakhs,” she adds.

TESTS & CARE PROTOCOL: INSURANCE FALLS SHORT

Then there are sophistica­ted tests. The family spent Rs 3 lakh on getting Meenakshi tested for the genetic marker that Osimertini­b specifical­ly targets. This is called the epidermal growth factor receptor ( EGFR), which accelerate­s tissue growth. Osimertini­b blocks the receptors on cancer cells and stops the cancer from growing.

To check whether Meenakshi’s cancer was EGFR- positive, her sample was sent to a laboratory in the US. “It took a while to confirm her initial diagnosis. Although her lungs were filling up with fluid — and the doctors suspected cancer — they came up with a confirmed diagnosis after a series of tests. We then sent the sample for gene testing. Although this can be done here, we were told that facilities in the US were better at mapping mutations and diagnosis,” says Yamini.

In the four weeks that it took for the US results to come in, Meenakshi had to be started on chemothera­py, the side- effects of which necessitat­ed additional therapies and expenditur­e. “We are fortunate to have the means but most people are unable to bear the costs of cancer treatment. They wait in long queues for months at government centres. Most families, including us, also have to ensure that we do not stretch ourselves too thin. There are other elderly and children in the family who would require health care,” says Yamini.

Nutrition is another component of cancer care. Fifty- three- year old Aasha Sharma* from Mathura, who has been living with the same type of cancer using the same medicine, is finding it tough to battle anaemia, one of the side effects. She needs a highprotei­n diet. “She has to take protein supplement­s, which are very costly,” says her husband Sunil*.

Can insurance cover be extended to these new therapies? Since targeted therapy is a modern treatment, most insurers fall short of including them in their plans on the ground that they are still in the experiment­al stage. Few companies with cancer- specific plans may cover it but with sub- limits. “Increasing­ly, cancer care — including day care treatments — is being covered by insurance providers and government schemes such as CGHS and ECHS. With routine costs being covered and insurance companies considerin­g additions, I expect patients to spend more on targeted, precision medicine,” says Dr Julka. However, an extended lifespan, at the moment, seems like an elite privilege. (* Names changed to protect privacy)