Oncology, Etc. - In Conversation with Dr. Peter Bach (Part 1)

"In part one of this two-part ASCO Education Oncology, etc. podcast, hosts Patrick Loehrer and David Johnson chat with health policy and payment expert, pulmonary physician, epidemiologist and writer Dr. Peter Bach about his background and career. Dr. Bach, who created the Drug Abacus, shares his views on cancer drug pricing, based care, and health equity. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at [email protected]."     Dr. Patrick Loehrer: Hi. I'm Pat Loehrer. I'm Professor of Medicine at Indiana University and Director of the Center for Global Oncology and Health Equity.    Dr. Dave Johnson: And hi. I'm Dave Johnson, Professor of Medicine at UT Southwestern in Dallas.    Dr. Patrick Loehrer: And this is Oncology, Etc. Welcome to the show. Dave, what have you been reading. There's a book that we chatted about earlier that I think might tie in today's discussion. It was called About Alice. And we both had a chance to read that book. I've met Calvin Trillin.    Dr. Dave Johnson: Yeah. We read it a few years ago. I think I recall us being at a meeting in San Francisco, and you mentioned the book to me. And actually, Calvin was a guest and a speaker at that particular meeting, so we both got a chance to have our copies autographed by him. It was an amazing book.    Dr. Patrick Loehrer: Yeah, just for the listeners, Calvin Trillin is a wonderful writer for The New Yorker, and his wife had cancer, had treated, and unfortunately developed complications in that. And this was kind of a memoir to this. One of the things I love is when they first met, they met at a cocktail party, and Alice was just stunningly beautiful—there's a picture of her in the book—and Calvin is not. He looks like Dave and I combined. But their eyes glanced, and in the book, he talks about the fact, years later, Alice said to Calvin, “You have never been as funny as you were that night.” And Calvin says, “You mean I peaked in December of 1963?” And Alice goes, “I'm afraid so.” So that resonates with me a lot, actually. But Dave, why don't you introduce Peter?    Dr. Dave Johnson: Yeah, happy to do so. It's been terrific to have him on today. Peter is a health policy and payment expert, pulmonary physician and lung cancer epidemiologist. He's a true Renaissance man. Peter spent nearly a quarter of a century at Memorial Sloan-Kettering, where he served as director of the Center of Health Policy and Outcomes. He has devoted his career to repairing defects in the healthcare delivery system that impede access to high-quality cancer care, and working to ameliorate healthcare cost crises. His work spans seminal studies, including the identification of racial gaps in lung cancer care, the development of the first lung cancer risk prediction model, lead authorship on multiple lung cancer screening guidelines, and definitional work on pharmaceutical pricing and value.    Last year at about this time actually, Peter moved to become the Chief Medical Officer of Delphi Diagnostics, a developer of blood tests for early detection of multiple types of cancer. Peter received his undergraduate degree from Harvard and medical degree from the University of Minnesota. He then took internal medicine training at Johns Hopkins, followed by a fellowship in pulmonary and critical care at the University of Chicago, where he served as a Robert Wood Johnson Foundation clinical scholar.    Along with his prolific scientific writing, Peter is a regular contributor to The New York Times and other newspapers. He is a frequent but fair critic of pharmaceutical drug pricing in cancer and a staunch advocate for value-based drug pricing. In addition, he has written extensively on a number of personal and provocative topics ranging from the death of his wife, medical school tuition funding, to setting physician reimbursement based on market forces.    Not surprisingly, he's amassed a number of accolades over the course of his stellar career, including, to mention a few, election to the American Society of Clinical Investigation, the Association of American Physicians, and the Johns Hopkins University Society of Scholars.    So Peter, welcome. Thank you very much for joining us.    Dr. Peter Bach: Oh, it's a real pleasure, Dave and Pat.    Dr. Dave Johnson: Well, why don't we kick things off by starting with a question we ask almost all of our guests? And perhaps just give us some little of your background, your upbringing, your early life?    Dr. Peter Bach: I'm a faculty brat from the University of Wisconsin. Both of my parents were on the faculty there. I grew up in Madison, which was a bucolic place. And I think early on was expected to be a doctor. My major defection from that was I majored in English literature in college, but I ultimately had a chance to circle back to that opportunity, spend a month with Nancy Ascher actually following her around one summer after I graduated from college, holding retractors during liver transplantation surgeries and other things. And it was a transformational summer for me. I hadn't been, you know, sort of pre-med, but that summer after college, the proximity to the human experience that being a doctor afforded and the opportunity to help people and use the few abilities I had in a productive way convinced me I had to go be a doctor.    And so I taught English for a couple years after college at two different boarding schools, and then went on to medical school with that very much in mind. I’m really privileged to have practiced for as long as I did before I turned most of my attention about a decade ago exclusively to research and policy.    Dr. Dave Johnson: That experience as a literature major, I think, is really an important one for medical students today. We still focus on science, which of course, is absolutely critically important. But the humanities are also extremely important, in my opinion, to that transition from being a doctor to being what I call a physician, someone skilled in the art of healing, and not just the knowledge of science itself.    Dr. Peter Bach: I agree with you. I think a core competency of practicing doctors who are empathetic and also who are better diagnosticians is having good listening skills. Listening and elicitation skills. I don't know if that comes from majoring in English, but you know, I think those sorts of perspectives that the person is more than just a vessel of signs and symptoms, I think, lays the groundwork for doing that well, I hope. The origin of the word doctor is, of course, teacher also. And so, communication is vital.    Dr. Dave Johnson: You mentioned that your parents were teachers at the university. What were their specialties?    Dr. Peter Bach: My father, who's gone now was a physician, but never practiced. He was a transplantation immunologist, laid much of the groundwork for solid organ transplantation and major histocompatibility complex was defined in large measure by his work and several others. He was the scientist who did the immunological compatibility work that led to the first bone marrow transplant, actually. And then my mom is a biochemist and also worked in genetics on the faculty there. And then they both moved, although separately, to the University of Minnesota, where I ultimately went to medical school.    Dr. Patrick Loehrer: So did it break their heart when you said you wanted to go into literature?    Dr. Peter Bach: No. What broke my father's heart was that I became an epidemiologist, which he always considered not really science.    Dr. Patrick Loehrer: Actually, I was thinking one of my favorite poets is William Carlos Williams, who just hung out in Paterson and delivered, I don't know, 1000 babies, but he used that experience with the patients to help guide his poetry. But I think as we get older, every patient we see, there's a little story in there that's really kind of unique. And so it's a great opportunity. Tell us a little bit about this transition from academia to industry. Is that an easy role? Tell us a little bit about that journey.    Dr. Peter Bach: Yeah, the transition was easy although not pre-planned, expected at some point. I'd reached a point in my life where I had done a great deal of things in the academy that I'm mostly proud of. I had accomplished a number of things that I wanted to accomplish. And like many researchers and, my health care policy work I consider to be research and exploration, I had reached one of the many plateaus you get to where I thought many of the questions and issues I'd worked on, I'd sort of resolved. Not that they had been fixed, but I had done the amount of disarticulation that I sought to do in that work.    And so I had reached a point where I wanted to figure out what my next new topic was, which I do, and have always done in my life for about a five-year cycle. And I decided my next topic was I wanted to do something new and work on something totally different, although with a lot of resonance to my past work. And the new thing I wanted to do was to be an operator, to work in a in a startup environment where I could play a small role in developing not only potentially important technology, and there's a scientific question in there that matters, but also build the culture of an organization and take the management and leadership abilities that I did trying to hone in the academy into other environments.    The most sophisticated word I can think of to describe it as it's awesome. I went not understanding the first thing about the technology, but understanding the clinical use case of it pretty well because of my background in prevention, early detection in lung cancer screening particularly, which is our first product is lung cancer prescreen biomarker test. I’m lucky to work with serious scientists who are also educators like Victor Velculescu who spends a huge amount of time, especially early on, spent a huge amount of time just teaching me about the technology, about echoes of DNA fragmentation, changes that you see as a result of cancers, abnormal mitotic cycle. All words I knew, but none that I've seen put together in a cohesive way. So I'm really excited about it.    And I think it may be the case that circulating DNA analyses or other kinds of biomarker assays for early detection of cancer, it could be that these are really transformational discoveries.  I want to be part of defining that field of keeping the rigor at the level it needs to be to think first and foremost about the tested subjects rather than sales of a test, and making sure that clinical studies and clinical use are carefully defined to ensure or make as likely as possible that the benefits exceed the risks for everyone who has a test like this.    That is difficult to do. The field is quite nascent. The reason we started in lung cancer, and the reason I was attracted to Delphi specifically, was that lung cancer has established clinical utility for screening itself. And the real problems we have with lung cancer screening relate to uptick, where at about 5% of eligibles being screened right now, even conservative calculations suggest we're losing 10,000+ people a year due to that shortfall. And my entire career has been focused on access to technologies, treatments, and other things like that, procedures at the level where we're bringing some of the health benefits that the technologies could provide. And so this is a different version of that same story.    Dr. Patrick Loehrer: If I can take you in the past a little bit, we had Deborah Schrag on a few months ago, and we were talking about Zaltrap and your role in that. It was really a rebellious moment, when you, I think, led the charge to challenge the price of this drug. Can you briefly tell us that story for our listeners? I think it's kind of interesting.    Dr. Peter Bach: Zaltrap. So I didn't lead the charge. I happen to be first author of the op-ed, but Len Saltz who ran Pharmacy and Therapeutics Committee is obviously a world-famous GI oncologist really was the motivating source of this. I got involved because he reached out to me and said, “There's this new drug, and I'm on the P&T committee. And we're going to reject it because it costs too much and it's no better than this less-expensive drug Avastin.”    He called me. We're friends. And I said, “Okay, you know, that's outrageous and exciting. How can I help?” And he said, “Well, I want to make sure we're right that it costs more than Avastin” We already had this system in place at that point. Since 2009, we've been posting cancer drug prices, which we calculated in certain ways that were robust and defensible and in the peer-reviewed literature and stuff. And so that got my interest very considerably. And then as he and I started to talk about it, I honestly don't remember which of us first proposed the idea that we not only reject it, but we announce it in some very flagrant way.    And I think for whatever reason, you know, we ended up saying, “Okay, let's just write an op-ed. Let's see if we can get an op-ed into a major outlet.” Then I'd written about this extensively. The basic argument is, there's so many layers of opportunity where pricing could be dealt with where it isn’t. And we were sort of the last frontier. So FDA could care about price. It doesn't. The Medicare could care about price. It doesn't. Although the new legislation that passed the Senate will change that if it passes the House and it's signed by the President, but back then that wasn't true.    And so we were like, look, we're the last man standing, if you will. We're experts in this. We can say definitively, we're comfortable with not having this drug because we have this other drug Avastin, which costs half as much. That means it costs half as much for patients, means it costs half as much for society. We're not going to use it.    And so we wrote an op-ed in The Times that got more coverage than we expected. Then a miracle happened. The maker of the drug, Sanofi, lowered its price to match Avastin. There was a little kerfuffle prior to that which all played out in the Cancer Letter where they initially said that our math was wrong. And then I think that was a mistake because then we showed that our math was right, at which point they had used up the one shot in their musket.    So yeah, so they lowered their price and a lot of good things happened as a result. Not the least, of which patients had access to Zaltrap, a perfectly good product for less money. But it was one of the events over the early last decade, that showed what a Potemkin village, this whole drug pricing thing is and has been all along, that these prices are not calculated based on the therapeutic value or the value to patients. And they're not carefully constructed, back calculated from the years of R&D from which they emerged or carefully titrated like the launch coordinates on a moon shuttle or something. They're made up simply based on what the market will bear. And that market has continually softened by rapidly rising prices. And the truth is the market isn't the patients paying for drugs, it's the doctors administering them. And because this was an infused drug, doctors make more profit on drugs that cost more.    So, what was terrific about Sanofi, essentially, overnight, although I think it was about a week, cutting its price by half, is it revealed the fact that the price in the first place was just a paper tiger. And they could just as easily charge half as much, just as easily cost twice as much. And that was terrific, because I think then, like I said, it was one of the events that began to drop the veil on how all of this pricing worked and how little it had to do with any of the claims the industry was making.    Dr. Dave Johnson: I mean, I saw that as a transformational moment. I think kudos to all of you - Len certainly and yourself, for bringing that to the public's attention. And you've actually even created a tool that I think you refer to it as your abacus. Could you tell us a little bit about that, perhaps?    Dr. Peter Bach: The Drug Abacus was a 2015 thought experiment. My team and I built it to essentially empirically counter or, if you will, test the pharmaceutical industry's narrative that their pricings were based on therapeutic value. And so the narrative up till then went like this: “Well, we price our drugs based on the value they deliver to patients.” That's what someone would say. And then I or somebody else would say, “Great. How do you define value?”  “Oh, you know, it's like love. You can't really define it.” Which makes the supposition or assertion both untestable and de facto untrue.    But nevertheless, the exercise was about okay, fine, let me dimensionalize love or value along the maximum number of dimensions I can think of. And actually, we did an update where we added more dimensions after we heard objections to the first. We basically said, “Look, the only things this could be is if it lengthens life, has low toxicity, it's for a rare disease, it costs a lot to develop, it's a particularly novel compound.” We just gleaned from prior statements from the industry and different companies what these dimensions would be. And then we took, I can't remember off the top of my head, 50, 60 of the most recently approved cancer drugs. And we measured each of these things. And we normalized them and we put them into equations. What was I think a good idea at the time, and the Drug Abacus, is the name of the tool is we didn't assign any values to each of these dimensions. Instead, we built a calculator, essentially a slide rule, where you could go in and whatever your vision was for how you should value a drug, like really life expectancy gains matter, really scientific novelty matters, or orphan status matters, you could re-weight them, essentially change the coefficients in mathematical language to see like, what should the prices be if you really care about X and care less about Y or whatever.    And then the other thing we did is we summed the total spending on these drugs based on real sales figures, and then allowed the total spending to change based on the modulated prices emerging from this calculator and carried with it two lessons. One was, there was no way to set these dials, and they were pretty close to infinitely flexible, to achieve current prices. There was no solution equation. And other people had shown that as well using different methods.    But the other is that you had to trade things off or you spent more money. And that is a key issue that I think has been recapitulated a lot over the last several years. And it's recapitulated again in the bill the Senate just signed, which was we want to lower out-of-pocket costs and total spending amongst Part D Medicare beneficiaries, we are capping it at $2,000, for instance. And if we're going to do that, the government's going to spend more money, where are we going to get the savings? It will be through lower drug prices on older drugs.    And so there's that classic trade off. The drug advocates illustrated both of those things. Then, like I said, we updated it later and added some other, I think, two more parameters. Results were the same, but if you will, it's a sort of classic empiric debunking tool with a lot of computer programming behind it. A lot of the work I'm proud of may not seem very ‘researchy’, but it derives the ability that my team developed to operationalize and empirically test claims about pharmaceutical innovation. And by doing that, you can essentially debunk if your instincts are right, or reaffirm or whatever.    Dr. Dave Johnson: I find it a fascinating tool. And, again, kudos to you and your team for doing so. I think it helps bring to light the challenges of pricing a drug appropriately in the market.    You've mentioned a couple of times now, the Inflation Reduction Act. What are your thoughts about that? Are you happy that this is happening? Do you think it's finally time that Medicare has the opportunity to negotiate drug prices, although hidden beneath that statement is for some drugs, I think is what the real bill says, but what are your thoughts about that?    Dr. Peter Bach: This is considerably more than half a loaf. You'd really have to never walk out and come out of the Ivory Tower to say it's not exactly what I would have done. And so I'm dissatisfied. The burden in just the Part D part, just if you look at the burden that beneficiaries in Medicare face on Part D drugs, it is alarming and unconscionable. The majority of people in Medicare, all of us, come from lives where we cannot relate to this, the median income in Medicare is $28,000 a year. And most people, they are not sitting on a few million dollars in savings. There's a sort of drip, drip declining asset value for them. And one of the five purposes of insurance is to catch people when something catastrophic happens to them and D doesn't do that.    People are wiped out. A third of people stop taking medicines and, recapitulating this theme of my work over, not just me, of course, many people work in this area. But from earlier, I think failure to develop new therapies is a scientific reality. Failure to figure out a way to make sure people can get them and benefit from them, that shows that we don't care as a society. And then I was really glad our team has done, back when I was at MSK, a ton of work clarifying that the real problems with drug spending were due to a fractured implementation of an established policy approach to how we pay for drugs, which is that they get time-limited monopolies during which the market sets their prices. And then those monopolies are over. And then society gets the benefit afterwards.    So there is this very clear transfer of who's getting the benefit, from the drug company to the people. And the people are taking the risk in that, in the sense that those new products are routinely eclipsed in terms of technological breakthroughs before it's time for us to get them super cheap. So we're bearing all that risk and that system has been broken. Like in the biologics, we still see biosimilars just chipping away and in some cases many biologics that should face competition don't.    And this institutional, and this is what we've been pushing for, for years, is that if you're going to talk about negotiation or changing prices or price controlling in certain markets, you need to focus on older drugs. Let the companies have their return and then focus on the older drugs and institutionalize that transfer the benefits to people and away from the companies.    And so that absolutely thrilled me. That is a recent change. The original propositions were all about launch prices, which I think is much harder to do. And if you want to do value-based pricing and assessment, with the current FDA standards about drug approvals, not necessarily even focusing on clinical endpoints, you are guessing, and so are the companies. But I think it's a much harder math problem and much more prone to error to do launch prices. This is like axiomatic. Since the ‘80s, this is the idea, the time-limited monopoly. So I'm thrilled about that. That's really appropriate. And then the whole insulin thing is just a mess. And I'm sure you've or maybe you haven't, but Mark Trusheim at MIT and I have been calling for profit regulation of insulin for a very long time. It's not full-on socialism, but this could be done at production plus, and it should have been done that way a long time ago.    Dr. Dave Johnson: Yeah, no doubt.    This concludes Part 1 of our interview with health policy expert and author Dr. Peter Bach. In the second part of this episode, Dr. Bach will share a deeply personal story of what it was like to care for his beloved wife, Ruth, who unfortunately succumbed to metastatic breast cancer at the much-too-young age of 46. We will also explore the challenging topic of delivering difficult news to patients.    For now, thank you for all of our listeners for tuning in to Oncology, Etc. This is an ASCO educational podcast where we will talk about just about anything and everything. If you have an idea for a topic or a guest you'd like us to interview, please email us at [email protected].    Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org.    The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.    Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.