PDT Across the Atlantic and Medical Economics

Does medical economics bias the community standards for treatment of skin cancers? If the answer is yes, then photodynamic therapy serves as an illustrative example of this bias.

Private practice dermatology in the US and National Health Service of UK are practice settings with significantly different economics and also different treatment goals. The one’s is to achieve the best possible outcome for the patient without regard to the third party cost (insurance company or Medicare). The other’s is to to take care of a population of patients given the limitations of access to healthcare. UK’s National Health Service is a government-run system with shrinking resources.

Here is a statement an article in 2008 from British Journal of Dermatology based on clinical research performed in hospitals and clinics of the NHS. “Photodynamic therapy is a good treatment for primary superficial BCC.” In fact, the authors further segment primary superficial BCC and claim that PDT is the treatment of choice in a low risk site (not in central face) that is greater than or equal to 2 cm.

On the other hand, a minority of dermatologic practices provide PDT in the United States. In some urban areas of the US, where there are more Mohs dermatologists than in some states, finding a practice offering PDT is unusual. The reasons are not just economic disparity among competing treatments. Reimbursement for PDT is not impressive – $175 for a 15 -30 minute treatment (Medicare pricing). Things just get worse from there. MAL and LAL (the two topical photosensitizers) are not approved by the US FDA for anything other than actinic keratoses (AK), while in Canada and Europe, similar agencies approved MAL for BCC treatment. No US pharmaceutical company finds economic benefit to the costly FDA approval process of MAL for use with basal cell carcinomas.

To add insult to injury, Gladerm, the only distributor of Metvixia (methyl aminolevulinate, MAL), the best porphyrin photosensitizer, is no longer offering the drug since the first of this year. There are no approved pharmacies in the US carrying FDA approved generic drug for compounding either. This leaves ALA (aminolevulinate) as the only available photosensitizer in the US.

Photodynamic therapy has not enjoyed much clinical application in the United States due to many reasons, but all stemming from underlying economic factors. The differences across the Atlantic can be explained by differences in reimbursement for the procedure: third party payor vs government-run health care. Another explanation may be the larger goals of treatment of these different healthcare systems: maximizing individual therapy and outcome vs managing a population outcome with limited resources. The question is what would the consumer pick if their face and wallet dependent on the choice?