Prices and value

When two expensive cancer drugs are combined, the price is often the sum of both even though the extra benefit is smaller. A rule for splitting the total value between them is needed.

Instead of letting a company charge more for a newly proven use of an old drug, payers would pay a one-off reward and keep the price low for everyone.

Countries buying radiotherapy machines one at a time pay high prices and get poor service. A single global buyer negotiating for dozens of machines a year could cut prices and demand long-term support.

Companies could choose to sell a new cancer drug at cost worldwide and instead be paid from a pooled fund according to how much health it actually delivers.

Small European countries have started negotiating cancer drug prices together. A bloc of large middle-income countries would have far more bargaining power.

Cheap, essential chemotherapy drugs like cisplatin run out because making them is not profitable enough. A non-profit maker could guarantee supply at a fair price.

Cisplatin and carboplatin cost a few dollars a dose yet ran short across the US in 2023 because too few makers found them worth producing; a non-profit maker with long-term hospital contracts would keep them on the shelf.

Once a class of antibody such as PD-1 blockers is proven, later copies could be approved on smaller trials showing equivalence, forcing price competition and freeing patients and money for genuinely new drugs.

Immunotherapy patents start expiring around 2028. Guaranteeing in advance to buy cheap copies for poorer countries would make sure manufacturers build the capacity.

Countries negotiate secret discounts, so nobody knows what anyone actually pays for a cancer drug. Sharing real prices between public buyers would strengthen every negotiation.

The FDA now requires new cancer drugs to prove their dose is the right one rather than the highest tolerated; asking the same question of the twenty best-selling approved drugs could cut doses, side effects and cost at once.

Copies of biological cancer drugs are still required to run large trials that rarely change the answer. Dropping them would cut years and tens of millions from each biosimilar.

When a cancer drug is approved for more uses, the company sells far more of it but the price stays the same. Japan cuts prices automatically when sales balloon; others should too.

Cheaper copies of biological cancer drugs exist but are used far less in some countries than others. Making them the default choice saves billions with no loss of benefit.

Pay hospitals a single amount for a whole course of cancer treatment, with extra for following the evidence, rather than paying per visit and per drug, which rewards fragmentation.

Governments and philanthropies would pay a company a one-off lump sum, set by auction to reflect the drug's social value, for the patent on a cancer drug with a large benefit in a common cancer, then let generic makers supply it worldwide at competitive prices. A pilot fund would buy out one or two oncology patents.

Oncology societies already grade how much benefit each new drug gives. Payers should tie the maximum price they pay to that grade.

Oral cancer drugs under Part D now have a yearly cap of $2,100, but infused drugs under Part B still carry 20% coinsurance with no limit; a Part B cap would close the biggest hole left in Medicare cancer coverage.

A single-centre trial at Tata Memorial found that adding nivolumab at about a twentieth of the usual dose to chemotherapy improved outcomes in head and neck cancer. Confirmatory trials against standard-dose immunotherapy are needed before low-dose labels could make immunotherapy affordable for millions.

Since 2016 England's Cancer Drugs Fund has paid a confidential discounted price for cancer drugs whose benefit is plausible but unproven, collected outcome data for two or three years, then had NICE decide for good; most drugs that entered were later recommended. Other systems could use the same managed-access deal instead of a yes-or-no at launch.

Taxpayers fund much of the science behind new cancer drugs but never learn what they cost to develop. Disclosure should be a condition of public payment.

US law lets a pharmacist swap an 'interchangeable' biosimilar without asking the prescriber, but earning that label used to need costly switching studies; the FDA now says those are usually unnecessary, which should be made permanent for cancer antibodies.

Since 2023 manufacturers must rebate Medicare when a drug's price rises faster than inflation; applying the same rule to commercial plans would end the yearly list-price rises that drive coinsurance up.

Immunotherapy antibodies stay active in the body for weeks, yet are often given every two or three weeks. After a few months, spacing doses out to every two or three months might work as well, with fewer hospital visits and much lower cost.

Most states require insurers to charge no more for a cancer pill than for an infusion, but the law does not reach the self-funded employer plans that cover most working Americans; a federal rule would close the gap.

Several treatments now work without chemotherapy, but most are given until the disease comes back. Giving them for a fixed time and stopping is the version patients would choose.

Health systems would pay for a $400,000 cell therapy only if it works. If the cancer has not responded by three months, the company refunds the price.

The PERSEPHONE trial showed six months of trastuzumab after surgery is as good as twelve, halving the drug cost; no company will run such trials, so public funders and charities must.

Under-the-skin versions of atezolizumab, nivolumab and pembrolizumab take minutes rather than an hour and need no infusion chair, so they can be given by a nurse near home, cutting facility fees and travel.

Companies get longer monopolies for rare and paediatric cancer drugs. That reward should come with a commitment to sell at cost in low-income countries.

Academic hospitals can already make CAR-T cells for a fraction of the commercial price. A public network would scale that so more patients can be treated for less.

Instead of shipping a patient's cells to a distant factory, hospitals would make CAR-T on site under a shared licence, cutting cost and waiting time.

Instead of making cell therapy from each patient's own cells in a factory, inject a particle that reprograms immune cells inside the body, made in bulk, so a dose costs thousands rather than hundreds of thousands.

Pay more for drugs that clearly help people live longer or better, and less for those that barely move the needle, using a public benefit scale doctors already use.

Companies extend monopolies on cancer drugs with dozens of minor patents and deals that pay generic makers to stay out. Closing these loopholes would bring cheaper versions years earlier.

Copies of the big antibody drugs are approved and cheaper, but uptake depends on each prescriber; letting the pharmacy substitute the biosimilar unless the oncologist objects would move most patients within a year.

Companies can license their patents to generic makers for poorer countries through a UN-backed pool, as happened for HIV. Only one cancer drug has been licensed so far; the whole essential list should be.

Regulators want proof a drug works; payers want proof it is worth the price. Agreeing both requirements at once would stop drugs being approved but then not paid for.

Instead of paying hundreds of thousands up front for a CAR-T or gene therapy, the health system would pay in yearly instalments that stop if the cancer comes back, so companies are paid for cures, not attempts.

Hospitals in the 340B programme buy cancer drugs at steep discounts but usually bill patients and insurers the full price; requiring the discount to reach low-income patients would turn a hospital subsidy into patient relief.

One immunotherapy may add years of life in one cancer and weeks in another, yet costs the same. Prices should track the benefit in each use.

Medicare pays clinics the drug's average sales price plus 6%, so a dearer drug earns the clinic more; replacing the percentage with a flat handling fee removes the incentive to pick the expensive option.

Most genomic and liquid biopsy tests are reimbursed on analytical validity and association with outcome, not on proof that they improve care. Paying for new oncology biomarker tests only inside registries or randomised studies, as Medicare did for PET, would sort the useful from the useless.

A single cell therapy can cost more than a house. Paying in yearly instalments, only while the patient stays well, spreads the cost and shares the risk.

The same chemotherapy infusion costs payers and patients more in a hospital outpatient department than in a doctor's office; paying one rate would stop hospitals buying clinics to charge the higher price.

For very expensive one-time treatments such as CAR-T, pay in instalments over years and stop paying if the cancer comes back, so price tracks the cure actually delivered.

Insurers already pay for off-label drug combinations that have never been randomised. Paying only when the patient joins a registry-based randomised comparison, as Medicare did for devices and the Cancer Drugs Fund did for cancer drugs, would turn that spending into evidence at no new drug cost.

When a health system pays for a new, uncertain cancer drug, it would require that every patient's outcome is recorded and that a pre-agreed analysis decides whether payment continues.

Health insurers and national health systems have every reason to find out whether half the dose or half the duration of a costly drug works as well. They would fund those trials directly and keep the savings.

If two drugs extend life equally but one makes patients much sicker, the health system should pay less for the sicker one. Build that into how prices are set.

Vaccines tailored to each patient's tumour mutations are showing real benefit but cost a fortune to make. Automate the whole process so a personalised vaccine costs about as much as a course of chemotherapy.

Individualised mRNA cancer vaccines take weeks to manufacture and work best against minimal residual disease. Making the vaccine at surgery and giving it only when a blood tumour DNA test turns positive matches both facts and concentrates the cost on the minority who will relapse.

Small countries pay more for the same generic chemotherapy because they buy alone; the PAHO Strategic Fund and the WHO essential medicines list show that buying together brings prices down and keeps supply steady.

Proton therapy costs far more than standard radiotherapy and, for most adult cancers, nobody knows whether it is better. Payers would cover it only inside trials or registries that answer that question, across every centre at once.

Countries buying cancer drugs alone pay more and face shortages. Buying together, as they already do for childhood cancer drugs and vaccines, cuts prices and secures supply.

Buy essential cancer drugs for many countries at once and license newer ones to generic makers, as was done for HIV, so prices fall to what those health systems can pay.

A trial can be designed to detect a tiny improvement that is statistically real but too small to matter. Protocols should state up front what size of benefit would be worth having, and be built to detect that.

Taking 250 mg of abiraterone with a low-fat breakfast gives the same PSA response and testosterone suppression as the standard 1,000 mg fasting, because food increases absorption several-fold, so a quarter of the drug treats each man. The label still says fasting and no company promotes the food-effect dose, so adoption is patchy.

A drug that adds a year of life in one cancer and six weeks in another sells at the same price for both; indication-specific prices would pay for the benefit actually delivered.

Drugs approved on early signs of benefit are paid for as if they had proved they extend life. Pay a provisional price and adjust it, up or down, when the survival data come in.

Hospitals in Spain make their own CAR-T for a third of the commercial price. Paying for such products at cost gives health systems a lever in negotiating with companies.

Cheap, essential chemotherapy drugs such as cisplatin keep running short because there is little profit in making them. A publicly-backed non-profit manufacturer would guarantee supply at a fair price.

Some expensive approved cancer drugs probably work as well at lower doses, as reduced-dose abiraterone with food and extended-interval checkpoint inhibitors suggest. Companies will not test this, so payers should fund randomised non-inferiority trials prioritised by spend and pharmacology, and use the results in reimbursement.

Abiraterone at a quarter dose with food matches full-dose exposure, and pembrolizumab and nivolumab can be given at longer intervals, but no manufacturer will fund trials that cut its own revenue. A public 'value trials' fund would run non-inferiority trials of lower doses and longer intervals for the highest-spend cancer drugs, with payers committing to adopt positive results.

Every targeted result on this roadmap depends on a test happening fast enough to act on. In England nobody publishes what share of lung cancers are tested, how long the test takes, or, in Wales and Northern Ireland, how long the lung pathway takes at all.

Immunotherapy is often given for two years or until it stops working, but responses can last long after stopping. Trials that randomly assign responders to stop or continue would show whether the extra year is needed.

Set the price of a new cancer drug provisionally, then adjust it up or down after three years depending on how well patients actually did.

Immunotherapy is given as one flat dose regardless of body size, which means smaller patients get more than they need. Dosing by weight would save a fifth of the drug at no cost to patients.

Cancer costs push patients into debt and make them skip treatment. Asking about money at every visit, and having someone to help, catches this before it does harm.

Cancer often ruins families financially, and money worries make people skip treatment. Ask about finances at the first visit, as routinely as asking about allergies, and route people to assistance.

Ask about money problems with a short validated questionnaire when treatment starts, and route those at risk to financial navigators before bills cause missed doses.

Weight-based doses rarely match vial sizes, so the leftover is discarded and still billed; closed-system vial sharing and rounding doses to the nearest vial within 10% eliminate most of that waste.

The fifth PD-1 antibody that is no better than the first should not get the same market protection as the first. Exclusivity would shrink for copies that add nothing.

Hospitals often lack the staff to switch patients to cheaper equivalent drugs. Private investors could fund the switching teams and be repaid by the health system from the money saved.

Instead of paying per dose, a country would pay a fixed annual fee and treat every eligible patient with immunotherapy. This has worked for hepatitis C drugs and antibiotics.

Monoclonal antibodies and ADCs have moved from weight-based to flat dosing on modelling alone, which is convenient but gives lighter patients relatively more drug. Randomised or pharmacokinetic comparisons, plus rounding doses to vial sizes where exposure is equivalent, could keep effectiveness while cutting cost and waste.

A randomised trial at Tata Memorial added nivolumab at 20 mg every three weeks, about one-twelfth of the standard dose, to cheap metronomic chemotherapy for head and neck cancer patients who could not afford full-dose immunotherapy, and they lived longer. Checkpoint inhibitors saturate their target far below approved doses, so publicly funded trials should test low doses in common cancers.

Lymphoma is among the most curable common cancers where the drugs exist. Rituximab is thirty years old and still out of reach for many of the people who need it.

Oncology has two respected scales that grade how much a drug helps in each indication; payers could set low copays for high-grade uses and require a conversation for low-grade ones instead of blanket prior authorisation.

When a cancer drug is added to the WHO essential medicines list, the maker should publicly commit to a low price and reliable supply for poorer countries, or the listing is withheld.

Reward companies that deliver a genuinely new kind of cancer drug with a sellable voucher for faster review of another product, but only if they agree to fair pricing and global access.

Generic imatinib and abiraterone can cost patients hundreds of dollars a month through insurance yet be sold at cost plus a fixed markup by transparent pharmacies; making that the default channel for oral cancer generics would save patients and plans money.

In a clinical trial the experimental drug is free to the patient and the payer, and since 2022 Medicaid must cover routine trial costs like Medicare and private plans do; pointing more patients to trials lowers bills as well as advancing science.

Scans at three months often cannot tell whether immunotherapy is working. A blood test at six weeks may give a clearer, earlier answer.

Some cancer pills are absorbed several times better with food, but the label says take them fasting at a high dose. Taking a quarter of the dose with breakfast can give the same drug levels at a quarter of the price.

India's 2012 compulsory licence on sorafenib cut its price by about 97% and its 2019 cap on trade margins lowered the shelf price of 42 cancer drugs; voluntary licences through a patent pool would achieve the same without a fight.

Biosimilars of trastuzumab, rituximab and bevacizumab have existed for years, but poorer countries cannot assess biologics themselves and place small fragmented orders. Extending WHO prequalification, begun with trastuzumab in 2019, to every oncology biosimilar and pooling procurement would give buyers assurance and makers volume, aiming below a tenth of originator prices.