Cancer and the cost of life
I spent a terrific hour yesterday interviewing my late sister Ruthie’s oncologist for the book I’m writing about her. It was an amazing time. He said that Ruthie was one of the most extraordinary patients he’d ever seen, and he credited the spirit and confidence with which she met her cancer with extending her life far beyond the norm for her type of cancer. When she was diagnosed, he said, he would have given her three to six months. She lived for 19 months, and lived richly, with joy. The doctor, who has been an oncologist for 25 years, was emphatic that her inner disposition had everything to do with this.
Which is not, of course, to diminish the power of chemotherapy, only to say that in his judgment, chemo alone couldn’t have helped her live as long as she did. Ruthie endured heavy, heavy chemo. I remember her telling me at one point that the cost for a particular medicine was something like $9,000 per dose — and she received a dose every two weeks. (I might have the details wrong, but the point is, the medicine that kept her alive cost some jaw-dropping amount). The doctor told me that Ruthie’s cancer was so serious that in her case, it was never a matter of curing it, only a matter of extending her life for as long as possible. Now, she had good insurance, which covered these treatments. But they were very, very expensive. Megan McArdle takes up the morality of new but pricey treatments. Excerpt:
Is spending $50,000 to give a pancreatic cancer patient an extra 5-9 months of life a wasted expenditure, or a medical advance? On the one hand, 5-9 months isn’t very long. On the other hand, for a typical pancreatic cancer patient, you’ve doubled their lifespan, which seems like a very long time indeed.
If we get better cancer treatments–which is what everyone says they want–we’re probably going to be asking those questions a lot. And either way, we aren’t going to like the answer.
True. If it’s you, or your sister, it’s very hard to put a price on the length of one’s days. My father would have sold everything he had to have given her one more week; in fact, he said he would do so, if it came to that, and I believe him. And yet, death will come for us all. Ruthie’s oncologist talked for a while about how fear of death harms the lives of cancer patients, diminishing their survival rates, and quality of life. At what point, though, do we say, “It’s not worth it to spend all this money to give Mrs. Jones an extra five months?” At what point does Mrs. Jones say that about herself? What about an extra four months? An extra three? You see how this goes. There are no good answers. But answers are required in real life.
UPDATE: A couple of you have sent me this terrific New Yorker article by Dr. Atul Gawande, on the difficult medicine has figuring out how to treat terminal patients who can’t be cured. Excerpt:
Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop.
The subject seems to reach national awareness mainly as a question of who should “win” when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we can’t afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But they’re debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper. To see this, you have to get close enough to grapple with the way decisions about care are actually made.