Public debate in Spain revolves around immigration, the fiscal amnesty for Catalonia and the price of housing and rent. Recently, the ‘Amyotrophic Lateral Sclerosis – ALS – Law’ was passed, a piece of good news that will contribute to improving the quality of life for these patients and their families. Another positive development has been the Ministry of Health's approval of two new drugs to treat different types of metastatic breast cancer.1,2
The first rule of Fight Club was not to talk about Fight Club. Media euphemism tends to avoid terms like ‘cancer’ or ‘metastasis’ in different reports. How many people die ‘from a long illness’? By using these vague expressions, the media not only diminishes the reality of the disease but also perpetuates a cultural silence around cancer, which can hinder open conversations about the challenges faced by patients and their families.
It is undeniable that cancer treatment has made remarkable progress since the 1960s, when the first studies with chemotherapy extended life by just a few months, up to the second decade of the 21st century, when the advent of immunotherapy revolutionized survival in some metastatic cancers. However, challenges persist, as in some tumors like pancreatic cancer or glioblastoma, significant advancements have not been achieved. Moreover, with the rise of the pharmaceutical industry, treatments offering marginal benefits at a very high cost have also emerged, raising questions about the sustainability of these decisions.3
According to data provided by the Spanish Society of Medical Oncology (SEOM), it is expected that 286,664 cancer cases will be diagnosed in our country in 2024, with the most common being colon and rectal, breast, lung, prostate, and bladder cancers. Regarding mortality, in 2022, 114,828 people died from cancer in Spain. According to data, population growth, lifestyle habits, and aging will cause cancer rates to progressively increase.4 Simultaneously, loneliness will rise and family support will decrease, as a result of the lack of natality-promoting policies and the economic difficulties faced by the younger population.
These are data that deserve greater attention from both society and the political class. Medical students should understand that, while a cure is not always possible, medical oncologists play a crucial role in easing the burden of cancer. They provide relief by managing symptoms, improving quality of life, and offering compassionate support to both patients and their families as they navigate the difficult stages of terminal illness. Each day, oncologists experience a mix of emotions – from the joy of small victories to the weight of despair and helplessness – reminding them that, even when a cure is out of reach, their presence and care make a profound difference. It is important to emphasize that the sense of failure should not rest on the deceased or their families. Rather, it is a failure of society, of the State, and of our politicians, who have created a fragmented system – ‘17 kingdoms’ – that perpetuates inequality across communities.
Recently, a drug called fruquintinib has been approved, which is an inhibitor of vascular endothelial growth factor receptors and is indicated for the treatment of patients with metastatic colorectal cancer who have progressed through several lines of treatment. In its clinical trial, it has shown an improvement in survival of 2.6 months.5 A true milestone. Two years ago, another drug called sotorasib was approved, whose mechanism of action targets the G12C mutation of the KRAS oncogene and is indicated for the treatment of metastatic non-small cell lung cancer. According to data from its clinical trial, sotorasib provided an improvement in progression-free survival (PFS) of 5.6 months compared to the 4.5 months offered by docetaxel, the standard treatment.6 The question of whether these marginal benefits justify the high costs is a legitimate concern that needs to be addressed in discussions about the sustainability of the healthcare system.
A month of treatment with sotorasib cost approximately 7000 euros in 2022, compared to 120 euros for docetaxel. At Medical Oncology conferences, it is often common to see enthusiasm and applause from the audience when these types of trials are presented. Fortunately, critical voices exist, led by experts such as Dr. Vinay Prasad, who often criticize the exaggerated positive response that these data generate. The cost-effectiveness threshold of $50,000 per QALY (Quality-Adjusted Life Year) has traditionally been used to evaluate whether new medical treatments provide a good balance between cost and health outcomes.3 However, with the rising prices of new cancer drugs, this threshold is increasingly questioned, as many treatments far exceed this limit without offering significant improvements in quality of life or overall survival. The need to reevaluate these thresholds becomes evident when facing drugs that are extremely expensive yet deliver marginal clinical impact.
It is crucial to consider the influence that the pharmaceutical industry may have on oncology practice. The promotion of new treatments with modest benefits may be driven more by commercial interests and influence over politicians and associations than by the true benefit they offer to patients.7 Critical evaluation and open discussion are two of the fundamental pillars on which the training of new medical oncology residents must be based.
My feeling is that, for the press, citizens, and patient associations, for those who are part of the Ministry of Health, it is often easier and simpler to post a message on X (twitter) or any social network boasting that the funding of a new drug has been approved, without detailing what benefit it will bring. How could anyone deny the approval of a drug that offers 1.5 months of survival, even if it costs 6900% more than the standard?
Couldn’t that economic difference be allocated to the creation of a continuous care law for patients with advanced cancer, which would be applicable nationwide and cover the needs for hospital transportation, home adaptation, and home care for patients with advanced cancer at the end of life?
Helping patients with advanced cancer and their families both economically and through supportive care, would it improve survival by more than 1.5 months? And what about the quality of life? If we are going to pay large amounts to the pharmaceutical industry, shouldn’t we demand better quality?
Authors in our country have perfectly defined what palliative care means and what it represents for patients and their families.8 The first place this message must be sent is to medical schools, and subsequently to the rest of society and our politicians. Providing tools to family doctors and unifying the foundations of a national palliative care program is crucial if Spain wants to adequately respond to an issue that could create an unsustainable physical and emotional care burden in the coming years.
The need for a unified and accessible palliative care system in Spain is becoming increasingly evident. Primary care, as the first point of contact in the healthcare system, will likely need to play a key role in palliative medicine and integrate some aspects of palliative care into the daily management of patients with advanced cancer. This must be accompanied by better resource allocation. Medical oncologists, given their experience in treating and assessing patients with advanced cancer, should also embrace their role in the development of palliative medicine, working closely with family doctors, palliative care specialists, and other professionals to improve this care. New programs, such as home hospitalization or close joint follow-up among several teams, could improve the situation.
I dream of a country of 48 million people, called Spain, that builds a centralized and strong healthcare system in which its citizens, especially those with advanced cancer, have equal treatment and opportunities, regardless of where they live. I dream of a palliative care law that guarantees access to economic benefits and home care for patients with advanced cancer. I want the experiences of palliative care doctors, psychologists, and nurses who care for these patients daily in Spain to be heard and valued.
“I hope that the wait doesn’t wear down my dreams” – Mario Benedetti
