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…and can we pay for it?
Patrick Cobb, M.D.
Medical Director
 I, Patrick Cobb, MD,
DO NOT have a financial
interest/arrangement or affiliation with
one or more organizations that could
be perceived as a real or apparent
conflict of interest in the context of the
subject of this presentation.
I, Patrick Cobb, MD,
DO NOT anticipate discussing the
unapproved/investigative use of a
commercial product/device during this
activity or presentation.
“Diseases desperate grown
By desperate appliance relieved.
Or not at all.”
Shakespeare
Hamlet
“Surgery is the ideal treatment.
It separates the disease from
the patient.”
William Stewart Halsted
Die magische Kugel
“Cancer therapy is like beating the dog
with a stick to get rid of his fleas.”
Anna Deavere Smith
Let Me Down Easy
“In solving a problem of this sort, the grand thing
is to be able to reason backwards. That is a very
useful accomplishment, and a very easy one,
but people do not practice it much.”
Sherlock Holmes
A Study in Scarlet
Arthur Conan Doyle
Barbara bradford
$4,700
>$40,000
 5% of NSCLC
 9,000 patients/year
 90% response rate
 60% alive at 2 years
 9% in control group
 $115,000 per year
 Melanoma with BRAF
mutation V600E
 60% of melanomas
 13.6 months
 9.7 months control
 $60,000 per year
Billion $
35
30
25
20
Cytotoxics
Targeted
15
10
5
0
2002
2012
 Total cancer spending
 5% of healthcare
 0.8% of US GDP
Inpatient spending on
cancer care
70%
60%
50%
 Percentage of total
medical spending
has not changed
in 20 years
40%
30%
20%
10%
0%
1987
2005
Annual deaths per
100,000
Five year survival rates
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
35
30
25
20
15
10
5
0
1975
2010
1975
2010
poo
kilpoonib
 Kilpoonib
 Phase I: some
responses in mutants,
none in wild type
 Phase II: 90%
response rate in
mutants
 FDA grants approval in
poo mutant colorectal
cancer
Colorectal cancer
Wild type
Mutants
 140,000 cases of
colorectal cancer
 50,000 will develop
metastatic disease
 10% are mutants
 Cost to bring a drug
to market:
$2-5 Billion
 Drug price:
 5,000 potential
patients a year
 $100,000 per year
 $500,000,000 revenue
 Kilpoonib:
 $100,000 per year
 90% response rate
 Only works in poo
mutants
 100 poo mutants
 90 benefit
 Total cost: $10 million
 Cost per response:
$111,000
 Oxaliplatin
 $40,000 per year
 30% response rate
 No specific target
 100 patients
 30 benefit
 Total cost: $4 million
 Cost per response:
$133,000
 Progress will continue
 Genetic research
 Protein expression control
 Role of pathologist critical
 Predictive models
 Target identification
 New drugs will be
expensive
 Much higher response
rates
 Specific subsets
Cancer is a word,
not a sentence.
John Diamond