Reducing Cancer Care Costs: Why Not Offer Neulasta in Smaller Vials?

This is the fifth in a series of posts on how we might reduce the costs of cancer care, based on 10 suggestions offered in a May, 2011 NEJM sounding board. We’re up to point 4:  oncologists should replace the routine use of white-cell-stimulating factors with a reduction in the chemotherapy dose in metastatic solid cancers.

In this section, the authors allude to what I think might be a cost-saving advance in oncology practice: why not make available lower doses of white blood cell (WBC) colony stimulating factors?

The issue is this: when people get high doses of chemotherapy, they’re compromised because the bone marrow doesn’t create new WBCs as it should. The risk of infection during chemo used to be so great that, in the 1980s and earlier, it was common for cancer patients to succumb to infection. With the advent of WBC stimulants in the early 1990s, the risks of infection during chemo dropped markedly.

These are complex and expensive drugs. And while I agree with the NEJM authors that chemotherapy is over-used, often, I don’t think it makes sense to cut down on potentially helpful doses or combinations of those drugs just because WBC stimulants are expensive.

Take Neulasta (pegfilgrastim), a long- acting stimulator of neutrophils manufactured by Amgen. This injectible drug costs over $ 2,000 for a single, 6 milligram vial. It’s supposed to be given every 2 weeks, although some oncologists might give it at a lesser frequency, depending on the chemo cycles. There’s only one size dose available for all patients; they’re all billed for the full 6 milligrams.

This is an ideal situation for Amgen, which takes in over $2000 for each 6 milligram vial. It’s far from perfect for patients who, even if there’s no toxicity, pay huge co-pays with each chemo cycle.

You can find some patients’ discussions of this issue at cancer support sites like these. There’s also a public correspondence between Medicare and the State of Wisconsin on the high costs of this drug.

Around 10 years ago, when I was practicing, I wondered why we couldn’t give some patients less than 6 milligrams of Neulasta. This would be useful in at least three situations: for patients who are physically small; for those who receive lower doses of chemo; and for people who are hyper-sensitive, for whom just a tiny bit is enough to raise the white count adequately. A frequent toxicity is bone pain; this is intense in some patients and, in theory, would be less problematic if a lower dose were available. Once, I almost got into administrative trouble for asking a pharmacist to draw up only half of the dose from a vial so that I might give a petite woman only 3 milligrams of this powerful drug.

Since then, nothing’s changed. I looked it up yesterday; there’s still only one dose of Neulasta: 6 milligrams.

So if Neulasta were sold in lower-dose vials, like 1, 2, 3 or 4 milligrams, patients could receive lesser doses, as is often appropriate. The costs of these drugs, when administered properly, might be halved, approximately, without compromising on recommended doses of chemotherapy.

Just my two cents, nothing more –

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  • I am a cancer patient. Nuelasta is a medication vital for survival. it cost a lot because our goverment is not doing their job of controlling the cost of this particular medicine. My insurance only pays $26.00 each treatment. which means i have to apply for bankrupcy after my treatment. i don’t know what to do to have this issues to be heard by everybody.I am hoping President Obama can read this e-mail of mine. i do know that the medicine can be very expensive, depending as where you get your treatment cause some provider they can charge you outrageous amount, it is unbelievable. somebody out there is not doing their job.

  • How can we get them to make Neulasta in vials. I have to give this to my 4 year old daughter once a week and she does not need to whole syringe, plus the needle is just to big. If it could be drawn up in an insulin syringe from a vial I am sure many people would benefit and save money. Please help!

    • Hi Jennifer, I wish I could help because I agree with you. It’s an expensive drug, needed but also with toxicity; you’d think someone would pressure Amgen to provide it in incremental doses – 1, 2, 3 kg, etc. If doctors could prescribe kg-based dosing, that would reduce side effects, drug “spilling” and costs.

  • I just had my first Neulasta shot and was in debilitating pain for three days even with Percoset around the clock! Blood work today showed that my white blood cells are way up – event thou they should be down since I’m in the middle of the NADIR timeframe ( I think that’s what’s it’s called, 7-8 day after first chemo?) Asked about reducing the dosage to my nurse ( before I read this) who stated ” we’ve never done that .” I will be discussing it with the oncologist in light of this article if not just for the cost, but to attempt to reduce the severe side effects.

    • Rosita, Thanks for sharing this story. Years ago, I tried a few times to give lower Neulasta doses – at least twice to avoid bone pain in an older woman with lymphoma who’d experienced that side effect, and in a patient who had a really leukemoid (high WBC, over 60K as I recall) reaction to her first dose. The pharmacist didn’t want to let me have a partial dose. It seems crazy that now, >10 years later, we still can’t get or give lower doses. And it’s so expensive!

  • For me it’s not about money. My hb receives a dose adjusted chemo and his is very sensitive to Neulasta – Neulasta does a great job for him. BUT from round to round of chemo he has different blood counts after chemo. Once he was almost neutropenic during chemo and he really needed those 6mg, but after two round out of current 5, he had wbc = 4, e.g. withing normal range. Sure, they dropping off slowly, but I guess for these two round he didn’t need the whole amount of Neulasta. The WBC dies in spleen, either their are ‘artificial’ after Neulasta, or normal, they do affect the spleen! There are several types of cancer that can be cured and the healthcare system and its providers should better think about possible long-term side effects for these cases as well! Neulasta is still a benefit/risk issue, so why AmGen still recommends a 6mg for everyone and in every case?

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