How Much Would You Pay to Survive Four Months Longer with a Terminal Disease?
When I was young enough still to consider myself rational, I was irritated by patients who tried any remedy in desperation to save themselves from their fatal disease. I have long since mellowed and when an acquaintance of mine with glioblastoma, a rapidly fatal brain tumor, decided recently to go to India to try Ayurvedic medicine, all I could do was wish him luck – sincerely so. After all, the scientific medicine -- which he would continue to take while there -- offered him little enough hope, a few months at most. (This case, incidentally, illustrates an important point: alternative medicine, so called, is not generally alternative, it is additional.)
Two trials of a very expensive monoclonal antibody, bevacizumab, in glioblastoma, published recently in the New England Journal of Medicine, make disappointing or even dismal reading. This antibody is directed at vascular endothelial growth factor that promotes the growth of new blood vessels; glioblastoma is a tumor particularly rich in new blood vessels, and so it was hoped that by preventing them from forming, tumor growth would either be prevented or at least slowed. Early results were promising but as has so often been the way in the history of medicine, early promise is not fulfillment of promise.
In one trial, for example, 637 patients with this terrible tumor were randomized to conventional treatment plus placebo and conventional treatment plus bevacizumab. Although the latter had a slightly longer period free of progression of the tumor, their overall length of survival was not increased, and indeed they suffered so many more side effects that the overall quality of their lives was worse. The patients taking bevacizumab survived on average 15.7 months; those taking placebo survived 16.1 months. The authors of the paper end:
In conclusion, we did not observe an overall survival advantage first-line use of bevacizumab in patients with newly diagnosed glioblastoma. Furthermore, higher rates of neurocognitive decline, increased symptom severity, and decline in health-related quality of life were found over time among patients who were treated with bevacizumab.
This makes rather odd the concluding words of an editorial that accompanies the trials in the Journal:
Finally, it is worth noting that despite its limitations, bevacizumab remains the single most important therapeutic agent for glioblastoma since temozolemide. Ongoing and future trials will better define how and when it should be used in this population of patients for whom so few treatment options currently exist.
Clearly the viewpoint of the oncological researcher is not that of the sufferer of the disease: he is looking far into the future, while the poor patient (all the poorer if he has to pay for his drugs) is thinking rather less far ahead.