On the occasion of Mother’s Day last month, the Ministry of Public Health (MoPH) launched a campaign to encourage Lebanese women to check for cervical cancer. Easily treatable when detected early, cervical cancer affects the uterus and is the third most common cancer among women worldwide. In the United States however, the disease is much less prevalent due to the well-established practice of annual pap smear tests; an example showing the importance of awareness and early detection campaigns.
According to the World Health Organization, the global burden of cancer can be reduced and controlled by implementing three strategies: prevention, early detection, and “managing” patients with cancer. The latter however, is a complicated and extremely costly affair as cancer requires a lengthy multidisciplinary treatment — often a combination of surgery, chemo and radiotherapy. Hospitals need to invest millions in the latest technology and patients need to cough up tens of thousands of dollars per treatment per year.
“Suppose you got an inheritance and decide to invest $100 million in a medical center,” said Professor Marwan Ghosn, head of the Hematology and Oncology Department at the St. Joseph University’s Faculty of Medicine. “A noble initiative, of course, but do not think you will make any money,” he asks rhetorically.
He explained that, in Lebanon, there are challenges for hospitals related to how they get paid for their services, where most bills are covered by either the MoPH or the National Social Security Fund (NSSF), with a smaller number covered by private insurers.
“In general, the MoPH pays years late, while the NSSF pays years late with cuts,” said Ghosn. “These days even private insurance companies pay late and will bargain for a package deal.”
He noted that payments suffice to keep management and doctors in a job, but hardly to invest in the latest medical equipment.
Finding the funds
Nearly all hospitals in Lebanon are facing financing shortfalls. The result is that many are inking alliances with foreign hospitals, while philanthropy is also on the increase, said Ghosn: “We never saw much philanthropy in Lebanon, but these days it is common practice.”
One medical institution familiar with sponsorship and fundraising is the Children’s Cancer Center Lebanon (CCCL). “We operate on an annual budget of some $12 million, some 80 percent of which is generated through fund raising, which varies from corporate funding and sponsoring of a single patient to our annual gala dinner the proceeds of which go to the center,” said CCCL General Manager Hana Chaar Choueib. “The remaining 20 percent comes in the ‘normal’ way by means of the MoPH, the NSSF, and private insurance companies.”
Affiliated with the St. Jude Children’s Research Hospital in Memphis, the CCCL opened its doors in 2002 and has since treated a total of some 800 patients below the age of fifteen. Every year the CCCL accepts some 70 to 80 new patients, yet on average it treats some 250 patients a year, as the treatment of leukemia takes some 2.5 to 3 years to complete. About a third of pediatric oncology cases in Lebanon concerns leukemia.
According to Choueib, the average cost of treating a child with cancer amounts to some $50,000 per year. More complicated and rarer cases however, such as bone marrow transplants and lymph salvage, cost up to $250,000 a year. “We particularly depend on third party generosity as it is our policy to accept children without discrimination,” said Choueib. “No parent should be worried about what and how to pay. They should only worry about the health of their child.”
Affiliated with Johns Hopkins International, the Clemenceau Medical Center (CMC) is arguably one of the few Lebanese hospitals that need not rely on sponsoring and fund raising to make ends meet. Currently, the hospital is set to invest $35 million in a special cancer center.
“The lion’s share of the $35 million dollar budget is to be spent on medical equipment. Our objective is to offer all the latest technologies under one roof to avoid people traveling from hospital to hospital, or even abroad,” said CMC’s chief executive Dr. Mounes Kalaawi. “We aim to attract patients to Lebanon.”
Progress at a price
Delete the cliché image of a doctor with stethoscope. Enter that of an engineer behind a computer screen handling a mouse. Today, even in the operating theater a single robot and controller can do what a dozen people did a decade ago. The technological revolution in the medical world however, comes with a hefty price tag and newly improved models and machines enter the market almost every year.
“We have pretty much replaced all imaging equipment since the CMC first opened its doors in 2006,” said Kalaawi.
Medical imaging has come a long way since scientists first detected the X-ray in 1895. Today, a hospital also uses computerized tomography (CT) scans, a combination of X-rays taken from different angles with which a computer produces a cross-sectional image. Magnetic resonance imaging (MRI) is a technique used in radiology to create images of organs and the body’s internal structures, while a positron emission tomography (PET) scanner is a nuclear imaging device producing a three-dimensional image of the internal body.
Yet progress has its price. While you can buy a simple X-ray machine for a few thousand dollars, a CT scanner costs over $100,000 and a medium-sized MRI scanner and PET scanner cost some $1.5 million and $2.5 million, respectively. And that is not all.
“In order to produce the radioactive material needed for a PET scanner, you need a lab and a cyclotron, which cost some $1.2 million and $2 million respectively,” said Wassim Boustany, sales manager at General Medical Equipment (GME), the authorized distributor of General Electric Healthcare in Lebanon. “There is only one such system at the Mount Lebanon Hospital, yet that is enough to provide the whole country.”
A complete oncology center furthermore needs two linear accelerators and bunkers (to avoid radiation spreading) for the radiotherapy unit. Total cost: some $4 million. Until recently, an analog mammogram system cost some $50,000 to $60,000. These days however, there is a digital variety on the market that is more precise with less radiation. Cost: some $350,000.
“From a personal experience I can say that most Lebanese hospitals used to be financially healthy, would make a profit even,” said Boustany. “Yet today some cannot even pay for maintenance cost and spare parts, as the end user simply cannot pay for the technological advancements. A PET scan costs about $1,000 in Lebanon. In the US it can amount up to $10,000.”
Nevertheless, there is generally no shortage of equipment in Lebanon. For example, the country has five of the latest PET/CT scanners, while GME is currently installing a combined PET/MRI device at Rizk Hospital, of which there are only 10 in the entire world.
Medication’s massive costs
“The cost of cancer treatment is determined by three components: the cost of medical equipment, the cost of medication and doctors and hospital fees,” said Ghosn who is also head of the CMC’s Hematology and Oncology Division. “In the diagnostic phase the patient pays mainly for the equipment. In the treatment phase, he or she mainly pays for medication. The new generation of chemotherapy drugs, for example, may cost some $4,000 to $6,000 per session, while in all stages the patient pays but a few hundred dollars on hospital and doctor’s fees.”
His view was confirmed by Rahif Jalloul, president of the Lebanese Society of Medical Oncology. “A six-month breast cancer treatment on average costs some $50,000, some $30,000 of which is spent on drugs,” he said. “The average patient would spend some $3,000 to $4,000 on X-rays and biopsies and, if needed, some $2,000 to $3,000 on surgery. In addition, a patient needs six sessions of medication [one every three weeks], which may cost up to $8,000 per session and I would not be surprised if one session soon costs $9,000 to $10,000. Radio therapy, if needed, costs some $5,000.”
Surgery, chemo and radiotherapy are the most common ways of treating cancer. Radiotherapy uses radiation to control or kill malignant cells. While it may prove a cure for some tumors, it is mostly used in combination with chemotherapy to prevent tumor growth or recurrence after surgery. Chemotherapy refers to the use of a cocktail of chemicals aimed at destroying cancer cells.
There are currently some 250 identified cancers and 50 commonly used chemotherapy drugs in the $1 trillion dollar industry. Last year, Hoffman-La Roche (Roche) spent 8 billion Swiss francs ($8.75 billion), or 22 percent of its global turnover, on research and development. According to a company brochure, it takes an average of $1 billion, 7 million work hours, 423 researchers and 6,587 experiments to produce one drug. The company then earns back such astronomical investments by being able to exclusively market the drug under patent.
“Research and innovation are at the heart of what we do,” said Abed Rahman Sabra, Lebanon Country Manager of Swiss pharmaceutical giant Hoffman-La Roche (Roche). “A certain minimum has to be set or else we will not be able to sustain our practices. You should know that we have hundreds of molecules under investigation, of which one or two will eventually make it to the market.”
Patented drugs generally enjoy a monopoly for 15 to 20 years, after which they can be produced by anyone. Yet often companies file patent upon patent in an attempt to extend the life of a drug patent and stop or delay generic drugs from entering the market.
As a result, as Matthew Herper wrote in Forbes last November, generic companies are constantly suing to invalidate extra patents, while brand name drug makers sue to keep generic versions off the market. “In theory, we pay more for branded drugs to finance the massive research needed to develop them,” he wrote. “But long battles over dozens of patents can simply distract pharmaceutical companies from their job: making new medicines.”
One such legal battle, which recently took place in India, could have global repercussions. On March 12, the Indian Controller General of Patents Designs and Trademarks ruled that the anti-cancer drug Nexavar was so beyond reach of ordinary Indians that he decided to sign a compulsory licensing order.
The German pharmaceutical giant Bayer that produces the drug had set a price of 280,000 Indian rupees or $5,448, which meant an Indian civil servant would have to work more than 3 years to pay for one month’s dosage of the drug. Based on the ruling, Indian firm Natco Pharma will now produce the drug for $172, while paying Bayer a 6 percent royalty on sales.
The case is already starting to shake the pharmaceutical industry. A few days after the ruling, Tuygan Goeker, head of Middle East and Asian markets at Hoffman-La Roche announced it would cut the prices of two cancer drugs, Herceptin and MabThera, starting in 2013. The wholesale price of the two drugs is currently $3,000 and $4,500, respectively.
While the advancements in medical technology and chemotherapy drugs have led to improved cancer treatment and a cure rate of some 50 percent, the cost of battling cancer and other diseases is imposing an ever-higher burden on society as a whole. Between 2008 and 2010, the MoPH’s annual drugs bill increased 73 percent to more than $60 million, most of which was due to ever more expensive cancer drugs.
In order to effectively deal with cancer, more emphasis needs to be placed on prevention and early detection. Measures such as an affordable check-up for cervical cancer, the annual breast cancer awareness campaign, and the announced ban on smoking are thereby but a start.
“To start with, eat less meat, avoid the intake of high-energy food and drinks, avoid food colorants, avoid smoked foods and eat more fresh fruits and vegetables,” said Dr. Jamil Halabi, Secretary General at the Lebanese Cancer Society. “And in the near future we must, for example, discuss the use of pesticides and insecticides.”
The bottom line is that without a fundamental change in the way our society operates, the number of cancer patients will only rise, and the costs of their care with it.
Childhood cure rate at risk
This year the Children’s Cancer Center Lebanon (CCCL) celebrates its 10-year-jubilee, and the institute has every reason to celebrate. “The cancer rate among Lebanese children has remained more or less stable since the 1960s, yet their survival rate for cancer has increased exponentially,” said Dr. Samar Muwakkit, associate professor of Pediatrics at the American University of Beirut and a leading doctor at CCCL.
Childhood cancer is not a common disease. Every year, less than 280 of Lebanon’s some 2 million inhabitants below the age of 15 are diagnosed with the disease. The most common childhood cancer is leukemia (one third), followed by brain tumors and lymphoma.
In the early 1960s, the survival rate of childhood cancer was a mere 20 percent, while 10 years ago 53 percent of Lebanese patients survived the ordeal. Today, the CCCL has achieved a cure rate of some 88 percent. Interestingly, it has largely managed to do so using the same drugs that were used in the 1960s.
“We achieved our cure rate by remaining extremely disciplined on protocol, constantly evaluating each dose and each patient, thus gradually advancing,” said Muwakkit. “It shows that, at least in treating leukemia, new technology and new, more expensive drugs are not necessarily the way forward. You do not always need to invest to advance.”
One might think that adult oncology (and the pharmaceutical industry) could learn something from its pediatric counterpart, yet some caution is necessary. “Firstly, cancer in children is easier to treat, as they are stronger and healthier than adults and react better on chemo therapy,” said Muwakkit. “Secondly, what is true for leukemia is not necessarily the case for solid tumors, which concerns the vast majority of cancers among adults.”
Today CCCL’s impressive cure-rates are under threat as a supply of the injectable, preservative-free drug imported from the US is fast running out. First developed in 1956, methotrexate is regarded as a lifesaver for children with Acute Lymphoblastic Leukemia (ALL), the most common childhood leukemia.
The acute cause of the shortage is that one of the largest producers of the drug, Ben Venue Laboratories, stopped production in late 2011 due to quality concerns. A more fundamental cause however, is the fact that a total of only five pharmaceutical companies in the US produce the drug and in February reports emerged that only a few weeks of supply were left.
Pharmaceutical companies make little profit on generic drugs like methotrexate, which costs $1.58 per vial. Compare that to the $6,000 paid for a single injection of the latest (patented) chemotherapy drugs. The issue of shortage in generic drugs has prompted US President Barack Obama to sign an executive order strengthening the FDA's power to predict and tackle shortages of prescription drugs and halt overcharging in times of scarcity. On February 20, the US Food and Drug Administration announced the immediate availability of relief supplies of methotrexate and also agreed with another manufacturer, Hospira, to immediately distribute 31,000 vials of the drug, which would meet nationwide demand for about a month. As for Lebanon and the rest of the world, the cost of curing childhood cancer may soon become a burden the youngest among us will have to bear even more.