Afsaneh Barzi, MD

This study shows we need to continue to look at the structure of the health care system in the United States. The results convey that this compartmentalized, broken down insurance system can actually translate to higher costs.

In this study, the most common treatment administered in the United States was FOLFOX. This regimen did not include the biological therapy, bevacizumab, that was used in the most common regimen in Canada.

The universal health care system is delivering perhaps more guideline-concordant treatment, which includes bevacizumab in the metastatic setting, and yet it has lower costs than the nonuniversal system.

This abstract does not tell us how much of the costs are related to hospitalization or physician visits, and how much of the costs are for actual treatment. Are there differences in the delivery of care? In other words, did we do more clinic visits for patients in the United States and are we doing more labs, or is it just the cost of treatment that is different?
However we look at it, it basically goes back to the source of the problem: When you have a health care system that is fragmented, it will affect the delivery of care, the outcomes perhaps, and the costs.

One of the arguments against a universal health care system is that it will result in inferior outcomes. In this study, the fact OS was very similar between the two populations is evidence that universal or generalized health care systems are perhaps not going to be inferior for health care delivery. It also is important to remember health coverage is not there for discovery. It is there to deliver something that already has been established. If that is the mission, then a universal system is not worse than the fragmented health care system we have.

Richard L. Schilsky, MD, FACP, FASCO

This study demonstrates it is possible to get equally good outcomes at lower cost in other health care systems. The United States is probably the only country in the world in which we actually have no real way of constraining the cost of health care. The FDA does not consider drug price in any of its deliberations about safety or efficacy, and whether drugs should be allowed to enter the market. Once they are on the market, Medicare is generally required by law to pay for the cost of these drugs. Private insurers typically follow suit, and there really is no way to put the brakes on the system. That is not the case in most other health care systems in the world. There typically is a regulatory body that determines whether a drug is sufficiently safe and effective to be made available to the relevant population, and then there is another agency — either a government agency or a government-appointed body — that does some sort of health technology or value assessment to determine whether the health care system can actually afford to introduce the drug into that particular population. That was the hypothesized reason why, in Canada, you can get what would generally be considered a very expensive treatment regimen in the United States at half the cost of what it takes to deliver a similar regimen in the U.S. and still get equivalent outcomes.

Wafik S. El-Deiry, MD, PhD, FACP

It is well-known that costs of health care in the U.S. are higher than most countries and that the U.S. is at the top of the list for dollars spent on health care as a percentage of gross domestic product in the entire world. It is, therefore, not surprising that the monthly cost of chemotherapy for metastatic colorectal cancer in western Washington is higher — approximately twofold higher —  compared with British Columbia across the Canadian border.

It is reassuring that the clinical outcomes are very similar with median OS of 21 to 22 months in both places. These numbers are somewhat lower than what has been considered the latest median OS in metastatic colorectal cancer of around 30 months.

The study documents a growing problem related to the cost of cancer drugs; the problem tends to affect those in lower socioeconomic status within the population. It would be interesting to get similar data for many other cancers and treatments, including immune checkpoint therapy, chimeric antigen receptor T-cell therapy and targeted therapy. It is interesting that, in the present study, the drugs being used have been around for many years and yet we still see the differences. Clearly the cost of drugs is a hot topic and requires solutions to address the serious issue of affordability of care at a particularly vulnerable time when facing a cancer diagnosis with often poor outcomes.