Expensive cancer drug – The tragic story of a cancer patient – News


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You don’t expect it – and then suddenly it’s there. Cancer. In Germany, more than every fifth person falls ill before their 70th birthday. What’s it like being terminally ill and not knowing if you can get cancer medication? A cancer patient tells.

Sarah Siksou is 46 years old and has cancer. She has completed 15 cycles of chemotherapy. She needs a break. Her doctor is hoping for the drug Tibsovo from the French pharmaceutical company Dienst.

Legend:

This drug was both a blessing and a curse for Sarah Siksou.

Deborah Schlatter

However, the drug has not yet been approved in Switzerland. Siksou’s doctor submits a cost credit request to the health insurance company. This examines it and rejects a assumption of costs. Siksou is outraged about this: “It can’t be the case that my therapeutic option vanishes into thin air because of one or the other’s greed for profit.”

On your own

After the cancellation of the health insurance company, she finally turned directly to the manufacturer, with the help of her lawyer and her doctors. Together they were able to negotiate that Siksou’s drug therapy is free every other month. She has to pay for 25,000 francs every other month herself.

Sarah Siksou only received the drug in the autumn of last year and has not yet had to pay anything. At this point in time, she does not know whether it will also affect her.

Helsana, Sarah Siksou’s health insurance company, wrote on request that it was a tragic case. Helsana receives more than 6,000 such inquiries every year, 80 to 90 percent of which are either approved immediately or allow a therapy attempt.

“A rejection only occurs if the legally required criteria are not met,” says the health insurance company. She tells Sarah Siksou that the price is too high and the benefit of the drug is too small.

Julian Wampfler from Inselspital Bern is Sarah Siksou’s oncologist. Many of his patients depend on medicines that are not yet approved.

Applying for cost credits is part of Wampfler’s everyday life and takes time. This is “very disturbing”, especially for patients like Siksou, whose lifespan is limited.

If a drug is not approved in Switzerland but is vital, Article 71 of the Health Insurance Ordinance applies. This obliges the health insurance company to check whether the costs will be covered.

Specifically, a doctor issues a cost approval to the health insurance company. One or more medical examiners from the health insurance companies check the application for effectiveness, practicality and cost-effectiveness and try to negotiate a price with the manufacturer of the drug. In many cases, the first step is a so-called therapy trial, in which the pharmaceutical company makes the drug available free of charge for a few months. If it helps, the health insurance company will cover the costs.

According to Article 71 of the Health Insurance Ordinance, does not reimburse any medicines that are not approved by the Swiss Medicines Agency, Swissmedic.

Unless they are on the so-called “specialty list” – which is not the case with the cancer drug Tibsovo – or certain conditions are met. All of the following conditions must be met at the same time:

  1. The disease is fatal or can lead to chronic health problems.
  2. A major therapeutic benefit is expected from the use of the drug.
  3. There is no effective and approved alternative.
  4. The therapeutic benefit must be in reasonable relation to the costs.

Points two and four were not fulfilled at Siksou. According to her health insurance company, the treatment is not economical and not effective enough.

In the case of Sarah Siksou, the health insurance company and Dienst were unable to agree on a price or an attempt at therapy. The manufacturer, Dienst, writes on request: “Servier does not communicate the prices of products that are not registered in Switzerland.”

Her case is particularly poignant for Siksou’s doctor. Because it is unusual for a seriously ill patient to negotiate directly with the pharmaceutical company. Not all people would have the energy and the ability to stand up for themselves like that. “But ultimately the situation is a result of the prevailing framework conditions,” says Wampfler.

Revision of the Federal Council


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In the past, health insurance companies had repeatedly assessed comparable cases differently.
Among other things, the Federal Council wants to change the framework conditions by revising Article 71 of the Health Insurance Ordinance. The goal is equal access to medicines. The health insurance should only pay for medicines for which clinically controlled studies are available.

Over 20 healthcare organizations have criticized this plan. You write: As a consequence, these drugs would no longer be paid for.

The back and forth with the health insurance company and the pharmaceutical company cost Sarah Siksou a lot of energy, as she says herself: “I find that very frustrating. It’s a one on one fight. If you don’t lead it yourself, nobody will lead it.”

In memory of Sarah Siksou


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Legend:

Siksou

Sarah Siksou passed away on December 7th from liver failure. She fought to the end – for herself, but also for others.

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