A woman receives Lecanemab, sold under the brand name Leqembi, at a hospital in Itabashi Ward, Tokyo. The Canadian Drug Expert Committee has shifted their stance, and is recommending that lecanemab should be publicly funded with conditions.Kota Kiriyama/Reuters
An expert committee at Canada’s Drug Agency has changed its mind: In February, it said public drug plans should not fund lecanemab, a drug used to treat the early symptoms of Alzheimer’s. Now, in July, after a “reconsideration process,” it is recommending that lecanemab be funded publicly – sometimes.
More specifically, the Canadian Drug Expert Committee (CDEC) has shifted its position from “do not reimburse” to “reimburse with conditions.”
Not exactly a ringing endorsement, especially when you consider that the list of conditions is as long as your arm.
But it has certainly caused a shift in public perception. There could soon be – at least theoretically - a drug available to treat mild cognitive decline, the early symptoms of Alzheimer’s.
So, what has changed in the past five months?
Not very much actually.
When the CDEC made its initial negative recommendation, the research showed that lecanemab (brand name Lequembi) could slow mild symptoms of cognitive decline by five to seven months over an 18-month period.
The research still shows that modest benefit, but the company presented additional data that show the stability of patients’ condition could extend beyond 18 months.
Essentially, without getting into too many technical details, the debate boils down to this: Is a reduction of half a point on an 18-point scale that measures cognitive ability a “clinically meaningful” benefit?
There’s no easy answer to that question.
In its reconsideration process, the committee mostly decided it should give more weight to the views of patients, families, and clinicians.
Again, there’s nothing wrong with that approach.
Except, with lecanemab, the principal argument presented was that the drug should be funded because there is no other treatment for mild cognitive impairment, so there is no other way of slowing down the cruel march of Alzheimer’s.
In other words, something is better than nothing.
All things being equal, that would be true.
A doctor points out evidence of Alzheimer's disease on PET scans at the Center for Alzheimer Research and Treatment at Brigham And Women's Hospital in Boston, Massachusetts. The CDEC calculated that, even with strict conditions, funding lecanemab would cost provincial drug plans $66-million in the first year, and $485-million by year three.BRIAN SNYDER/Reuters
But this drug is costly, and requires a lot of other resources. There are not only direct and indirect costs, but tremendous opportunity costs – other ways we could be using the money that might be spent on a drug with, at best, marginal benefits.
And that’s the issue we should be discussing. Not whether or not lecanemab should be paid from the public purse, but how public health care dollars are spent more broadly.
Yet, in Canada, every decision seems to be made in splendid isolation, with no attention paid to the big picture.
To be eligible for treatment with lecanemab a patient must have a diagnosis of mild cognitive impairment or mild dementia owing to Alzheimer’s. (The wait time to see neurological specialists in Canada is up to a year.) Genetic testing is required because people with two copies of the gene variant APOE4 are not eligible. (It’s not a routine screening test.) The drug is infused every two weeks in a hospital setting. Patients also require regular MRI scans. (The wait time for MRIs can be months.)
It is debatable whether the system could administer this drug effectively. The CDEC also says the drug should be funded for six months, and discontinued if the disease progresses to moderate dementia. But our system is terrible at saying “no.”
The gift of care for people with Alzheimer’s disease
Lecanemab costs about $30,000 a year.
The CDEC calculated that, even with strict conditions, funding lecanemab would cost provincial drug plans $66-million in the first year, and $485-million by year three.
Is that the best way to spend public dollars for dementia care? Or would that money be better spent on rehab and home care?
Beyond cost, there is always the question of value for money, something we tend to pay very little attention to in Canadian health care.
The CDEC calculated that the incremental cost-effectiveness ratio for lecanemab was $288,760 per quality-adjusted life-year. (A QALY is a health metric used to measure the overall value of medical treatments; anything below $50,000 is considered cost-effective.)
In other words, the price would have to come down substantially before it’s considered a good investment.
If the provinces accept this recommendation, they would try to negotiate a lower price, but would it be low enough?
Every new drug promises dramatic benefits. It’s easy to offer hope, especially when it comes to incurable conditions like dementia. But it’s far more difficult to deliver.
The question we really need to be asking is: Is this the best way to use our scarce resources? Even if we may not like the answer.