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Recently, members of the pharmacy and therapeutics committee at Memorial SloanKettering Cancer Center (MSKCC) in New York reported that MSKCC will not offer ziv-aflibercept (Zaltrap, Sanofi Oncology) to patients with advanced colorectal cancer at their hospital, because the drug is too expensive.1 This decision was reached despite data from a double-blind, placebo-controlled, randomized trial showing that adding ziv-aflibercept to chemotherapy improved overall survival in patients with refractory colorectal cancer previously treated with oxaliplatin. And the decision was made despite the approval on August 3, 2012, by the FDA for use of ziv-aflibercept in combination with FOLFIRI chemotherapy. Notwithstanding the trial data and FDA approval, MSKCC staff called the decision a “no brainer.” The median survival benefit with the drug was minimal (1.4 months); the drug has a similar mechanism of action to bevacizumab, which is already available for advanced colorectal cancer; and the drug price—$11,000 per month—was astronomical compared with the merely exorbitant bevacizumab at $5000 per month. This is surely not the first formulary decision to be made with cost in mind, nor is it the first to recommend against new, expensive treatments with minimal advantage over other options. I suspect that almost every hospital and clinic formulary committee in the country has made similar decisions for all sorts of drugs, from antibiotics to chemotherapy, and for all sorts of medical equipment and devices. Of course, every business in the world chooses supplies based on cost, usefulness, and alternatives. However, the decision at MSKCC, and more particularly its public declaration, may serve as a “shot heard ‘round the world” for voluntary limits on the use of expensive oncology drugs. And like that famous shot fired by Massachusetts minutemen at a bridge in Concord, this decision both reflects rapid cultural changes and will require far broader support and ammunition to have lasting effect. With that understanding, several features in this decision warrant greater awareness and appreciation: • Academic centers are becoming cost conscious. Many academic cancer centers are under increasing pressure to show value and cost awareness. Historically, they have been perceived as expensive places for treatment. Whether this characterization is fair is a different discussion. Regardless, academic hospitals are seeking ways to show that they can deliver cost-effective care. One way is to disavow expensive, relatively ineffective treatments or interventions. Academic centers are now incentivized to identify such opportunities to curtail cost without meaningfully affecting outcomes. • Academic centers are uniquely positioned to make tough choices about appropriate use. As home to distinguished clinicians and investigators, academic oncology centers have the expertise and reputation to decide what the best treatments are, as well as where and when to incorporate novel therapies. Many academicians are also familiar with guideline or pathway development and thus have perspective on where within treatment algorithms such novel approaches belong. Finally, the nature of academic centers as non-profit institutions with salaried clinicians liberates academic hospitals and practitioners to do the right thing without undue preoccupation with personal gain. The role of arbiter for treatment choices is a tremendous value-added contribution from academic cancer centers and should be widely recognized as one of their important functions. • Public disclosure of treatment recommendations is critical. An anonymous shot in a forest has none of the impact of the same shot fired across a public bridge. The Harold J. Burstein, MD, PhD

A “Shot Heard ’Round the World” on Cancer Drug Costs?