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Comment by dumbmrblah | Hacker News Reader

MD and I work in the field. The technology is called CAR-T, as the article mentioned. It’s been used pretty widely for “liquid” tumors for a while (eg leukemia, lymphoma, and multiple myeloma),but solid tumors are particularly difficult to target using current CAR-T therapy. If this CRISPR tech can be applied widespread to solid tumors that opens up a huge swath of patients that can be treated.

However cost and logistics are a huge factor. CAR-T therapy currently cost about $300,000-$500,000 to treat a patient. Beyond the cost of the immunotherapy you require a huge institutional investment because there are characteristic side effects that occur within the first 30 days of treatment which necessitates patients to be either admitted to the hospital for 30 days or stay in close proximity with daily check-ins (yes the cancer is getting treated BUT now your immune system is hyperactive which can be very dangerous in the short term).

Very few academic hospitals, let alone community hospitals, have this bandwidth which will lead to cancer care being concentrated in a handful of a few very large cancer specific institutions.

View on HN

This isn't CAR-T, which is a chimeric antigen receptor (antibody) grafted onto a T cell. This is a T cell with an edited TCR receptor. This is quite different and comes under the 'adoptive TIL' category of treatments. It allows targeting of antigens not displayed on the cell surface. Every cell has to process their protein through a proteasome and present those peptides on the cell surface, which is where the advantage of this type of treatment comes in. In CAR-T we target a surface protein, and there's nothing to stop the cancer removing that protein from the cell surface.

For comparison on the cost question:

I received conventional, pre-CAR-T treatment for ALL Leukemia about 9 years ago. That consisted of chemo, total body irradiation and a successful bone marrow transplant. Cost was $300,000.

Are you sure THIS treatment above is only 500k? It’s too bespoke and no way I can imagine it costing less than a few million per patient.

I responded to another post similar down but you are correct. The drug is $500k, the surrounding medical care / hospitalizations etc pushes the total cost to over $1,000,000

>The drug is $500k, the surrounding medical care / hospitalizations etc pushes the total cost to over $1,000,000

In the US. Outside the US, hospitalization isn't that expensive.

For reference, here in South Africa, it's about 250$ per day of hospitalization. Or 1500$ for ICU hospitalization per day.

And we have private Healthcare here.

Pardon me.

Is the 250$ per day in a public or private health facility?

Private, though you don't pay it out of pocket for 95% of stuff as the medical aid covers it using your premium. Public is probably much much cheaper (free) but not a place any sane middle class person here would ever want to experience.

US healthcare really does put a new spin on the term "life savings".

Here in the Democratic People's Republic of Sweden healthcare is government funded and universal.

Independently of where one stands politically, we Swedes are lucky that our government can import expensive medical treatments from large evil US corporations that do the work for us.

Its not like US is the only manufacturer of medical tools which and treatments for the only way to pay is via that ridiculous medical system they have there. Thats a nice fable that US pharma would like you to believe since they profit from it generously.

Those items are done all around the world, ie in Switzerland. And a lot of tools come from ie Germany (Siemens), Netherlands (Philips) etc.

I chuckled when I read this, because when I think about the "brand" for Philips/Siemens, my default assumption is "American company". When you mentioned it, I recalled "Oh yeah, I've heard that Siemens is german before", but being raised with the "American Exceptionalism" mental framework means this thought isn't the default. (Versus brands like Volkswagen/Ikea/Toyota).

Embarrassing example: I was watching Federer play Nadal and thought "Wow, American athletes are great. I'm proud that we have the best. Wait... neither of these guys are american. Let me google where they're from. What am I so proud of exactly??"

The number of times we hear "this is the greatest country in the world" on a daily basis is really quite sad.

I am not trying to come across as patronizing, but the US is, in my opinion, the greatest country in the history of the world.

I am sorry that you feel that way about your country as a fellow human (I am not being sarcastic), but my positive view on American exceptionalism has nothing to do with you personally, just your culture.

Americans are often embarrassed of America, which I think tends to stem from the fact that they think it can be even better than it is. Which isn’t a bad way of looking at things, IMHO.

The US has for 70 years enjoyed the distinction of being the most powerful country in the world by various reasonable metrics, almost certainly the most powerful to have ever existed. But is it the greatest country in the history of the world? Depends on what you mean by "great". We've undertaken atrocities; started wars; destabilized entire regions. Despite being unbelievably rich we have people dying to treatable illnesses like diabetes for lack of medical care. We face more violent crime than other comparably rich nations, and whole swathes of non-white individuals have valid reasons to fear the very police force that should serve a protecting role. Despite being in certain respects undereducated, we saddle those who seek higher education with enormous debt burden. I could go on and on.

I'm not saying that other nations haven't done things worth vehemently criticizing, but it seems a bit ... gauche to call the US the greatest country in history full stop.

One metric, in fact the only metric for me as father of 2 small children currently is: where do I want to raise my kids, to have the best environment to grow up, to be happy, know true freedom and have these qualities transfer also into adult life?

Despite all its qualities and uniqueness, objectively US wouldn't rank in first 10.

If you re-read my comment and the comment I was replying to, you will see that I wasn't making any claims about America being or not being the greatest country in the world. I was pointing out how "American Exceptiolism" will sometimes cause me to think things which "are great" as being american when they aren't american at all.

* you: Swedes can import expensive treatments from US corporations

* Parent: Alot of those are from non-US (Switzerland, Germany, Philips)

* my comment: When I think of "Philips", I think it's an american company

* my comment: When I was watching 2 top athletes, my default assumption was that they were american, even though it's extremely obvious that they aren't. Which exposes how ridiculous the framing is.

Unless a company actively promotes that it’s a foreign company in their branding, “German engineering”/“Swedish design” or similar with their name/branding, I will assume it’s an American company.

I think one of the reasons "American Exceptionalism" is dangerous, is that it holds us back from improving on things which aren't actually the best. If an American politican says "This is the greatest country in the world", that is an emotional argument to keep things exactly the same.

Makes sense, thank you!

I’m sitting here in America, literally half a mile from one of Philips major research facilities. I know folks who work there - although many are Indian grad students.

Not sure how the whole “German” thing is relevant.

I live near a big tech campus and am surrounded by foreign firms who do massive amounts of R&D in my neighborhood.

The US is of course not the source of all the tools. But the ability to charge Americans high prices for novel treatments make the US the dominant source of funding for clinical and pre-clinical medical research, whether or not those funds flow into German tooling.

German designed, American funded.

Who said anything about medical treatments?

This is like complaining about how much it costs to buy a car because gasoline costs too much.

The cost of staying in a hospital bed in the US is ridiculously expensive, without any treatment at all, much less advanced drug therapies.

Would the Democratic People's Republic of Sweden be willing to drop that kind of dole on a single patient? It seems wasteful to me.

yes, in the Democratic People's Republic of Germany (specifically in the anarchist Berlin enclave), a friend of mine received successful cancer treatment that ended up costing well over 500k (and she is not even German)

Reading stuff like this just short circuits my brain because I can't even fathom such a society existing. Yet, it clearly does.

this member of the anarchist enclave berlin is paying 750EUR per month (plus the 750EUR my employer does) for these treatments. solidarity ftw!

That sounds potentially pretty similar to US insurance costs.

Germany has a different setup than most EU countries: one can be insured privately or publicly.

Public insurance costs are based on income. Private insurance costs are based on health/age etc.

Moving from private insurance to public is almost impossible, as far as I know.

To give you an idea, I recently switched to private insurance and cut my monthly cost by 50%.

Depends on your definition of waste. Is it wasteful if it ends up saving a life?

But it could save more lives if spent differently.

So you're saying we should kill most people the day they become pensioners? Because at that point the vast majority have negative economic value ...

Are you saying hospitalization isnt that expensive to the patient or where its socialized medicine the overall cost?

It's not as expensive as the US, but it's still bloody expensive to get intensive care in a hospital.

It's not unusual for a premie baby who stays in an nICU in Canada for a month to have a treatment cost well over $500,000.

Actual cost, or billed cost? Because they're not the same.

There is no difference in Canada for public hospitals. All billing rates are set by the government.

OP is talking about CAR-T therapy which is in routine clinical practice. In the UK costs have gone from £600k to around £250K That includes the surrounding medical, nursing and follow up care. In the US costs are likely to be more than that.

The article is talking about a very bespoke process where they take a patient's cancer, sequence the whole thing, select mutations they think will be presented on MHC-1, predict the antigens visible, and 'somehow' (I need to read the article more carefully to figure out how they did this) select a TCR sequence which will bind to that. Then they use CRISPR to graft that onto the TCR gene of a T cell from the patient (3 types by the looks of it), and re-infuse the targeted cells.

So yes, that would cost several million.

> that would cost several million.

But it sounds like many of the steps should be amenable to an engineering solution so the cost should fall dramatically if only it can get started.

And the first sequencing of the human genome took 10 years and cost hundreds of millions of dollars. Today you can do it for $100 in a couple of hours.

The same will happen with CAR-T and CRISPR.

Does that $300,000-$500,000 go mainly to super-highly qualified labour, expensive materials or rare machine time? Still more or less on par with a few rounds of chemo.

Good question and I should have been more clear. The drug itself is $300,000-$500,000. It’s crazy expensive, but it’s not like a hedge fund patenting 100 year old insulin or something, it’s a bespoke medication. I still think they are price gouging however.

The medical care would likely add another $500,000.

https://ashpublications.org/ashclinicalnews/news/3469/CAR-T-...

All in about $1,000,000 per patient.

There were some drama in England about NICE not willing to put the medication on NHS formulary because of the sheer expense. Is it better to treat 1000 diabetics or one cancer patient?

https://www.biopharma-reporter.com/Article/2018/09/21/Novart...

They ultimately approved it.

What do you estimate is a fair price?

My question would be more like, what would be needed for it to fall to 10% of its price ? Still only limited to developed world, but at least would make it more accessible

Well what makes the drug so expensive? Is it mostly mark-up for a high risk venture, is it actually taking 2+ man-years to formulate the drug for a particular patient, does it require already expensive components/reactants/whatever, bespoke machinery that would only produce a few doses in its lifetime, or some combination thereof?

Not responding with regard to any specific treatment, rather more generally. It’s a mixture of several things: * New/Niche Equipment * Few few commoditized inputs (e.g. lentiviral vector) * Labor Intensive * These setups look more like labs than large continuous or batch manufacturing sites * Everything requires GMP * This can mean weeks of training new personnel (even for well known manufactures) * Additional time & resources for FDA approval (safety testing, documentation, validation,

This is a good reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5363291/

We need to massively scale back regulatory regimentation in medicine

"FDA Deregulation Increases Safety and Innovation and Reduces Prices"

https://marginalrevolution.com/marginalrevolution/2022/11/fd...

We will never get the pace of innovation and price reduction in medicine that we see in more market based product classes if we don't.

Seriously, innovation needs to be encouraged and all the gates hamper that. But being critical of the medical cartel gets flagged/downvoted quickly here. See comment higher up.

It might reduce prices, but I wouldn't trust pharma companies to put safety over profit. We've seen time and time again that pharma companies will do the bare minimum to prove safety, which has lead to a large amount of harm (see Vioxx, Thalidomide, etc). I don't think reducing what safety measures they have to prove will make therapies safer.

The study on medical devices indicates that safety actually improves with deregulation, due to the combination of a larger market and litigation.

In any case it's obvious to me at least that in the long run, if medicine sees the same pace of innovation that, say, smartphones have seen, or even that the cosmetic surgery field has seen, we would have much safer medical products and services just by virtue of them being significantly more sophisticated, less invasive etc.

Finally - even if all this weren't true - without price reductions, it will be increasingly the case that the safest and most effective treatments will be out of reach of the masses, due to simple economics/scarcity. I would rather have some lower quality products/services available to the public, and the best quality ones be more accessible, than remove the lower quality offerings but also deprive the public of the best quality ones.

Why this choice? In the case that a treatment is life-saving the ethics board can approve experimental treatments on a case-by-case basis. Medical laws just don't allow patients to make this choice for themselves.

The problem with the centralization (regulation) approach is that it assumes one body can be chosen that will be optimal at risk assessment. In practice, the process of developing good risk analysis frameworks - that strike the right balance between cost, risk and efficacy - is often best discovered through trial and error, and that requires the freedom to try new products in the market.

There's an ethics board per hospital. And there's different countries. You can in fact shop around if that's what you want to do. You can do this, both as a patient and as a pharmaceutical company. It's just really expensive.

Even a law requiring an ethics board, with statutory requirements for how that ethics board is constituted, is a one-size-fits all meta-solution, created by one body: the national regulator.

> The study on medical devices indicates that safety actually improves with deregulation, due to the combination of a larger market and litigation.

I doubt it, very much.

Appropriate regulation, not deregulation, is the name of the game.

>>Appropriate regulation, not deregulation, is the name of the game.

Based on what case studies of industries? Look at the prices in the most regulated sectors. In medicine, it makes the most effective treatments inaccessible to the wider public, with innovation that reduces costs progressing at a glacial pace.

Pharmac and Medsafe in New Zealand.

Medsafe regulates medicines, what is effective, and Pharmac buys them, for the whole country.

Pharmac drives hard bargains with pharmaceutical companies. There is a lot of money to be made (even in a small market like New Zealand) if a medicine is -bought (read subsidised) by Pharmac.

The effective treatments are available. The highly experimental, might work, might not, might kill you, might make you sicker, might cure you medicines are held at bay by medsafe, and when approved are made affordable by Pharmac.

Of course Pharmac is under constant attack by the completely unethical pharmaceutical industry and equally unethical senior doctors - all hopelessly corrupted by the enormous sums at stake. Huge astroturfing campaigns exploiting ill people and their families. But the benefits are so huge that it has survived.

There is talk about extending the model to medical devices and consumables.

Appropriate regulation is absolutely needed because the incentives that drug companies and medical equipment manufacturers face are opposed to the incentives of the community.

Free markets, in this case, make people sick and impoverished.

>>Medsafe regulates medicines, what is effective, and Pharmac buys them, for the whole country

This is no different than what happens in the UK and you're gonna run into the same problems that the UK has where cutting edge treatments cost too much for the government healthcare program to cover them.

The problem in medicine is that innovation is too expensive, and too slow to rollout, and this applies just as much to New Zealand as anywhere else.

Cancer and heart disease should have been cured by now, considering the pace of innovation we know is possible.

>>medicines are held at bay by medsafe, and when approved are made affordable by Pharmac

You can't legislate affordable cutting edge treatments into being. Pharmaceuticals have to be incentivized to spend vast sums on developing them, and a mechanism needs to exist to select the best amongst those treatments for further development.

Evidently, that selection and resource allocation role is best left to consumers and their doctors, as opposed to one centralized body.

>>Appropriate regulation is absolutely needed because the incentives that drug companies and medical equipment manufacturers face are opposed to the incentives of the community.

Their incentives are to be selected by consumers, and the best way to do that in medicine, like any other industry, is to produce high quality products at low cost.

See the study on the positive effects of down-regulating medical devices, which are lower prices and greater safety.

>>Free markets, in this case, make people sick and impoverished.

I still don't see the basis for this assertion.

Safety can legitimately be in the backseat when you're trying to cure a disease that has a 50% chance to kill you in a year.

Its not just safety, but to prevent shady people from taking advantage of desperate people.

> Safety can legitimately be in the backseat when you're trying to cure a disease that has a 50% chance to kill you in a year.

Yes.

Standards are lower in that case. Back in the 1990s when I was up to date, clinical trials for HIV ad cancer treatments were truncated.

We saw the rapid development of COVID vaccines recently, much quicker than normal drug development

Sometimes availability is more important than safety. Let the patient decide if they want to take the risk, just mandate they be informed.

I'd be curious to see what would happen if reasonable regulations stayed in place but we capped/removed the risk associated with litigation (assuming regulations were followed). I.e. what portion of "adhering to regulation" is reducing the speed of advancement because of fear of litigation, as opposed to just the cost of sticking to the regulation.

To put this in perspective, a family member was treated for leukemia and our billed* medical expenses hit $300,000 in the first 2 weeks of treatment. This included the initial hospitalization, attempted install of PIC line, install of broviac catheer. And secondary hospitalization in hepa controlled room due to other illness during an immuno compromised period.

The standard treatment continues for ~2.5 years so this was only a small portion of the bills we received.

*obviously what is paid by insurance + out of pocket is very different, but that level of billing is insane. Also you really don't want to be fighting insurance and the medical center over billing while your family is undergoing cancer treatment.

This was at UCLA

Part of the NICE discussions is to apply pressure to get a lower price. I feel like this is a good thing to prevent gouging. The second version of the Cancer Drugs Fund is also useful here, because it makes available stuff that isn't in the BNF.

The draft guidance is here: https://www.nice.org.uk/guidance/ta567/documents/appraisal-c...

It's long and detailed and it'd be unfair of me to pull anything out specifically.

How do hospitals spend $10000 to $16000 a day?

To pay the people who make these things happen I suppose.

Is that the real COST or the markup "cost"

Probably both, they've got to make back the cost of developing and testing the therapy, but there's probably a profit markup on top of that.

US-based pharmaceutical companies maximise their margins in the US to make up for smaller margins in other markets. In many other countries, most prescription drugs are purchased by the government, which gives the government a lot of bargaining power which it uses to drive margins down. Prescription drug purchasing is much more disjointed in the US (negotiating with many private insurers instead of just the government), giving more bargaining power to the vendors and supporting higher margins.

This doesn’t make sense. Consider two scenarios: company ABC sells only in the USA and Company XYZ is otherwise identical but also sells to Asia.

You are implying that because XYZ has lower profit as a percentage yet higher profit as a nominal dollar amount, that XYZ will charge its American patients more. My intuition says both ABC and XYZ will charge Americans the same, namely the highest amount it possibly can under market/regulatory/PR/competitive considerations.

The same that happens in medicine happens in college textbooks - and other forms of high margin, but relatively fixed/finite initial investment and stable cost to produce.

American scholars write some of the most respected textbooks in the world, they are then sold in US colleges for $100-400/each. The same book is then sold in SE Asia and Africa for $10-40/each.

Don't forget R&D costs

But please pay no attention to marketing costs.

Also, don't forget government money for funding of research.

The madness of the US healthcare aside, CAR-T is really a somewhat complicated therapy. There are no economies of scale there, unlike in pills. Each patient requires a lot of painstaking work that can only be done on specialized machines by highly qualified people, plus the safety requirements are really high.

Activating the immune system is risky. It is strong and it can crush cancer in mere weeks, but it is also very dangerous to friend and foe alike. Basically, you gather a lot of absolutely ruthless and stupid troops and tell them "here is ze Flammenwerfer, burn the enemy to crisp, but don't destroy anything else".

Easier said than done.

I sadly know little about all this technology. It is fantastically expensive at the moment from what you say. That keeps it away from the vast majority of cancer patients in the world.

Technology does tend to get cheaper over time, though not always.

Do you think this treatment could reach $30.000 in 2,5,10,15 years? And $300 in another 10,20,50 more years?

> Technology does tend to get cheaper over time, though not always.

What technology didn't get cheaper?

Although I'm hesitant to make strong statements because inflation plays a significant role here, cars are much more sophisticated than they used to be but also very expensive as a result.

Depends on the car… there are still some extremely cheap options out there that do a surprising amount of stuff.

I think that depends on what you classify as "extremely cheap". The cheapest car in the U.S. market is the Spark at under $14k, but it's been discontinued. The Versa and Mirage both start around $16k.

I'm unaware of anything else under $20k, although the Ford Maverick is impressively reasonable at $21k.

In 1916 a barebones model-T cost $360 [1]. That's $8400 in 2019 dollars, and $9800 in 2022 dollars. This is actually what led to the normalization of planned obsolescence. [2] The widespread availability of reliable and cheap vehicles posed a problem for manufacturers which had, to that date, primarily just competed on quality and price.

What do do when you can't create something more cheaply, or of a higher quality? Curve some edges, strap a layer of chrome on it, and market it endlessly to get people to buy the fundamentally identical product over and over and over again. Progress!

"Oh god, I can't believe you're still driving a 1916 - that's soooo last year."

[1] - https://modeltfordfix.com/the-1916-model-t-ford/

[2] - https://en.wikipedia.org//wiki/Planned_obsolescence#History

> In 1916 a barebones model-T cost $360 [1]. That's $8400 in 2019 dollars, and $9800 in 2022 dollars.

Not too much like a modern car to compare, though. Still no electric starting, and not a lot of capacity, creature comforts, or speed. Time between major overhauls was ~15,000 miles. Overall lifespan of the car was estimated as 100,000.

> What do do when you can't create something more cheaply, or of a higher quality? Curve some edges, strap a layer of chrome on it, and market it endlessly to get people to buy the fundamentally identical product over and over and over again. Progress!

When we're comparing to vehicles with anything like modern speeds and capacities,... average vehicle age / longevity is higher than its ever been. (It's a bit more difficult to compare before the mid-1960s because vehicles were rebuilt and overhauled so much before then...)

I don't think technology improving over long time scales runs contrary to the nature of the question, or answers it. The first computer, the ENIAC, required a small building of space, cost about $6 million, and ran at around 500 FLOPs. Today a modern GPU is several inches long, costs a couple of hundred dollars for a pretty decent one, uses minimal electricity, and will run literally tens of billions times faster than the ENIAC.

Well, overall hedonistic adjustments to price are complicated and controversial.

I'm just saying: there's not really any cars like a model T anymore. Not just because of increased technology, but because of improved underlying technology: customers expect more (volume, mass capacity, interior comforts, ancillary features, speed, etc) and that increases cost.

We could probably make something a lot like a model T pretty cheaply still, if there were a big market for it.

Also, the government makes it illegal to make cars like a model T now.

Insecure cars are not road legal, but reliable cars are perfectly road legal.

> because inflation plays a significant role here

A new, average midsize new car in 1985 was approximately $11,000. (~$30,500 after inflation).

A new, average midsize sedan is now approximately $31,886.

In 1927 Model A Ford in the Town Car configuration was $1400-- this is like $24,000 now, but of course, it's a lot less car than a modern midsize.

IMO, car pricing hasn't changed much.

Today’s car is safer, more fuel efficient and more capable as well.

Not in the medical field, but space flight?

I think the point is that technology that has to constantly progress to stay relevant doesn’t stay cheap.

Space-X has lowered costs by almost an order of magnitude, if I remember the numbers.

I don't think this is true. It's something Musk likes to say, but a source would be useful.

I'm sure the launch costs (which can be worked into $/kg for payload) can be easily looked up, and show that SpaceX's reused rockets are much cheaper than what came before.

Falcon 9 is as cheap as Proton M according to something google found somewhere.

Do you have a source?

We haven't seen a reduction in space insurance premiums of any particularly large magnitude which I would expect if the costs of launching satellites into space had been substantially reduced.

SpaceX is a small fraction of total lifts though.

Something like 20-25% of all launchs globally doesn't seem like a small fraction.

> What technology didn't get cheaper?

Insulin.

In the US.

Yeah, Europe bends us over on pricing.

Though plain old insulin is actually pretty cheap. It's the fancy stuff that's really expensive.

ti calculators

Hearing aids

Like a lot of things, you need to add "in the US" to stuff like this, because outside the US these things are dirt cheap.

Sadly, physical calculators will soon be extinct as it will be replaced with calc app on the mobile phones.

The fact that hasn't happened after 15 years of smartphones suggests it won't happen at all.

There's still a market for dedicated calculators. Schools don't allow students access to smartphones during tests, but calculators are fine.

Because of calculator lobbyists?

because of schools and cheating

Insulin, also a lot of pharmaceuticals have gone up over the past 10 years, at least in the USA from price gouging.

Webcams. They have barely improved in the last 10 years technology wise, and in fact even got more expensive due to covid.

Phone cameras have improved phenomenally and are great webcams. You can even clip them to your laptop if needed.

For webcams we now also have eye/head/movement tracking, automatic background insertion, and other improvements (as well as added features like turning you into an animated cartoon character) although arguably those are from webcam software rather than hardware (though there are examples like the Apple Studio Display webcam which uses their neural engine hardware.)

> What technology didn't get cheaper?

Military hardware?

Small planes. The exact same plane from the 1970s costs 4x as much.

Those fancy digital glass cockpit avionics in the modern versions are not cheap. On the other hand, those ancient mechanical avionics were crazily expensive, too.

When I say the exact same plane I mean the same plane, not one with fancier avionics.

Same model from the 70s with the same avionics in 2022? I'm not sure that's even available. C172 entry model is full glass today. Interior looks a lot more shiny, too.

Maybe not same model but actually same plane? If it was new in the 70s it is used and much cheaper now. If it was new in the 50s, the used price in the 70s might have been lower than it is today though. That's caused by the minimum price the market defines for anything that's airworthy.

Maybe that's an investment stragtegy, buying used planes when they reach their minimum price, then keeping them, flying minimal hours to keep the engine alive, to sell 50 years later. But any potential gain will be neglected by hangar and maintenance cost.

This is criminally underinvested.

General aviation is quite a ways behind where cars are right now. There are new planes like the Cirrus SR22 that have made advances, but they are far from ubiquitous. Most GA planes are like driving a 57 Chevy except if the engine dies, you die.

Obviously not op, but it sounds like the issue is that the cure makes you sick in the short term which requires expensive care. If the sickness is inherent to the solution it’s hard to see how this gets cheaper.

The next generation CAR-T treatments are supposed to be "easier" on the immune system and hopefully don't require the prolonged hospitalizations. But that is 5-10 years away.

As with many medical drugs, the marginal cost of production of the medication is small, but it is dwarfed by the cost of research, trial conduction and FDA approval and is patented. Additionally for CAR-T there is rather intense post-adminitsation care required.

For the pharma research companies to be profitable, they need to recoup the above costs on the limited number of cancer patients there are.

For a widely applicable technology like CAR-T, if you can figure out how to distribute the costs over multiple types of cancers, you could have a much larger pool of patients to distribute the cost over, such that the marginal cost of production is a more meaningful component of the cost to patient/insurer.

Pharma typically spends a lot more on marketing than research. In fact, there is little to no correlation between research costs and the cost of a drug.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5559086/

https://www.wired.com/story/drug-research-pricing/

https://www.washingtonpost.com/news/wonk/wp/2015/02/11/big-p...

https://www.cbsnews.com/news/higher-drug-prices-support-prof...

There are companies doing research in applying CAR-T for treating animals. This has a much easier approval process since it is run through USDA and not FDA. I'd expect to see faster advancements in treatment and lowering costs and then having this tech brought over to humans later.

I've watched the prices of patented drugs quadruple in less than 5 years, to the point where a 30 day prescription can cost thousands of dollars despite the same medication costing $40 in countries like the UK. Drug companies have absolutely no reason to drive down prices of the patented treatments they have a literal monopoly on.

Corporate capture

Cancer won't be a problem by 2027, at least for the people who don't already have cancer. By 2030 there will be drugs that can even cure stage 4 cancer with next to nothing side effects. (AI and some form of quantum computing will help find these drugs)

That seems like a very confident statement. How are you reaching that? (Other than a magic AI.)

Quantum is not at that point, and won’t be in 3 years.

Researcher working in a related field. The above is just patently false. There are currently no drugs that can do this in lab-animals, let alone make it through clinical trials in time by 2027.

Computation is also not the bottleneck of research, it's the amount of training data, see ICGC https://dcc.icgc.org for the current state of the art.

Remember that each tumor has 3 billion base pairs (A,C,G,T), each of which can be duplicated, deleted, mutated. It can also be affected by methylation. Expression of the genes comprised by these base pairs is also affected by the micro-environment of the cell. Any machine learning model will have far to many parameters for far to few observations, to pick the rare drug that can cure stage 4 cancer (assuming it even exists) out of millions of possible chemical compounds.

Another therapy mentioned often in the comments here CAR-T is at the moment around 300k from the pharmaceutical companies.

A study in germany predicts a cost of around 30k if universities or other bigger health care providers create the CAR-T cells in their own labs.

> which will lead to cancer care being concentrated in a handful of a few very large cancer specific institutions

Wouldn't that be a good thing? Aren't specialized hospitals better at treating things that they specialize in?

From what OP said, I doubt they'd be able to keep up with the additional load of patient care (admittance especially) so there could be long wait times.

At some point, capabilities like this mature on the science end but are slowed down on technology (scaled manufacturing). That would take significant investment by a big pharma or a new venture-backed investment to go after things like this. Fingers cross this happens within my lifetime.

From the article: >“This is a tremendously complicated manufacturing process,” says Joseph Fraietta, who designs T-cell cancer therapies at the University of Pennsylvania in Philadelphia. In some cases, the entire procedure took more than a year.

Good for people with money, resources to know where to get the best treatment and live close by; bad for everyone else.

Disclaimer: I work at a giant cancer institution.

This sounds like something that works out with time and scale. Thanks for the insight.

Do you know if CAR-T or CRISPR technology goes into the brain?

There are clinical trials on Glioblastoma CAR-T treatment but it faces the same problems as any other solid tumor - namely the solid tumor microenvironment is not amenable to the current generation of CAR-T treatments

In addition one of the dreaded side effects of CAR-T is neurotoxicity. CAR-T can cross the blood-brain barrier and leads to inflammation in the brain. You can treat it pretty quick with steroids but this side effect along with several other pro-inflammatory ones is the reason for the 30 day hospitalization sp treatment.

I seen what inflammation in the brain causes, not pretty.

Not CAR-T or CRISPR AFAIK, but there's been some recent breakthroughs with getting treatments past the blood brain barrier, and promising glioblastoma treatments are in the pipeline as well. This is just what I've seen on the internet news, you'd find more than I know about it with some internet searches.

I hope you aren't affected by GBM. If you are, or someone you know is, my only advice is to live life to the fullest while you can and don't let yourself fall into denial of the prognosis.

Not me but my wife. Will just put this out there for anyone else, the advancements made in Cancer treatment in the past few years are impressive. Don't lose hope.

Also, listen to your doctors as all of the sudden everyone is oncologist. Listen to your doctors, seek second opinions, do research but question everything as there is a lot of snake oil for sale.

I'm so sorry. My mom was diagnosed a few years ago and she got preyed on by snake oil salesmen to the tune of 6 digits. The money doesn't matter to me, but people are really fucked up.

I can recommend Duke's neuro-oncology center though. They did a great job with her when Sloan Kettering wouldn't touch her.

Best of luck to the both of you and hang in there.

> yes the cancer is getting treated BUT now your immune system is hyperactive which can be very dangerous in the short term

Can immune-suppressive drugs be used during treatment?

All of you AI people reading this should work on predicting side effects and outcomes from these therapies. That would help decrease the cost tremendously.

What is MD?

Medical Doctor in the United States. Undergraduate (4 years) + Med School (3 years) + Residence (1 to 3 years), roughly.

If money weren’t an issue, which institution/doctor would you send a loved one to if they needed such treatments?

You'll want to sign them up for a clinical trial. Only CAR-T cell therapies that are FDA approved are for leukemias. [ and as a commentator points out, for lymphomas, I had always thought lymphomas were a subset of leukemia. mea culpa ]

I personally got CAR T-cell therapy (Yescarta) for Primary Mediastinal Large B-Cell Lymphoma:

https://www.yescarta.com/

https://en.wikipedia.org/wiki/Axicabtagene_ciloleucel

> On 1 April 2022, the FDA approved axicabtagene ciloleucel for adults with large B-cell lymphoma (LBCL) that is refractory to first-line chemoimmunotherapy or relapses within twelve months of first-line chemoimmunotherapy.

I was in a clinical trial, though, but that was to determine the effectiveness of Anakinra in preventing serious side-effects; in my case, I only got a few mild fevers, which is the biochemical equivalent of winning the lottery, in a lottery where losers end up comatose and intubated.

https://en.wikipedia.org/wiki/Anakinra

I am very happy for your outcome, can't imagine the stress and fear you felt. So glad you had success, let's hope this becomes commonplace and people are saved from such a wretched fate.

I'm also very happy, especially since I was in complete remission as per a PET/CT scan a month after infusion after my cancer had survived two previous lines of chemotherapy (DA-EPOCH-R and R-GemOx) and had even shrunk but became more metabolically active after the second line. I'm still in complete remission, with further destruction of the tumor, six months after infusion, and there's some evidence the CAR T-cells can persist a decade after infusion:

https://www.nature.com/articles/s41586-021-04390-6

This story made my day.

We need more stories like this.

Incorrect. Yescarta, Tecartus among others are approved for certain types of lymphoma.

Multiple myeloma has Carvykti and Abecma

https://www.cancer.gov/sites/g/files/xnrzdm211/files/styles/...

With respect to institutions:

East coast: Sloan Kettering in NYC and Dana Farber in Boston

Middle America: MD Anderson in Houston

West coast: City of Hope and UCLA in Los Angeles.

Hutch/SCCA?

Took my wife to MSK for a second opinion on the treatment plan for her ovarian cancer. They were beyond useless. They wouldn’t say or recommend anything until the current treatment plan (eg round of chemo or surgery) was complete, yet it was incredibly difficult to arrange time with them to review results when that time came.

Basically we got nothing from them.

Not sure what my point is other than if you’re getting a second opinion, discuss how the provider will integrate their assessment with the existing treatment plan. And at the end of the day it’s the doctors and nurses you get that make the difference in your care, not the building.

I hope that this didn’t negatively impact your wife’s outcome and that she got better care elsewhere.

Thank you. We visited Cleveland Clinic as well and received very similar results. I briefly thought about starting a class for cancer patients to help them navigate the medical system in the US. I had to try to learn to fly from the front seat of the plane and it was a bad experience.

She passed in 2020, just two years after diagnosis.

I am sorry for your loss.

How do they handle controls in cancer trials? Is it compared against what is otherwise the standard of care?

There's not one answer but often: yes, split into "arms" receiving SoC or trial.

Details on this is part of the trial listing which is usually on https://clinicaltrials.gov/

Ahhh, personalised treatment for the mega rich. Soon our billionaire gods will be able to live far beyond a normal lifespan. I wonder how this will impact society?

If it wrecks the rest of social media the way it's on its way to destroying Twitter, could be a long term good for everyone.

Rich get a few years head start while effectively financing the making it cheaper part. Not “fair” but at the same time there is trickle down.

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