British Cancer Patients Denied Costly Drugs

August 08, 2008 05:50 PM
by Denis Cummings
The British health care system decided Wednesday not to cover four effective cancer drugs due to high costs, prompting a debate about the price on life.

NICE Rules Against Coverage of Cancer Drugs

The four kidney cancer drugs—Sutent, Avastin, Nexavar and Torisel—have been shown to extend life up to six months or longer. They are widely used in western Europe and America, and were covered in parts of England before Wednesday. Other care options for kidney cancer patients, namely interferon, are largely ineffective.
However, the National Institute for Health and Clinical Excellence (NICE), an agency that advises Britain’s National Health Service (NHS), has determined that the NHS should not cover the drugs because they are not cost-effective.
“Although these treatments are clinically effective, regrettably the cost to the NHS is such that they are not a cost-effective use of NHS resources. [They] have the potential to extend progression-free survival by five to six months, but at a cost of £20,000 to £35,000 per patient per year,” says NICE’s clinical and public health director Peter Littlejohns. “If these treatments were provided on the NHS, other patients would lose out on treatments that are both clinically and cost-effective.”
The decision has angered doctors, charities and patients. “Together these drugs are the single greatest advance for kidney cancer patients in the last 20 years, yet I and my colleagues face the prospect of being unable to offer treatment that is absolutely standard in every other western European country,” said kidney specialist Tim Eisen. “This decision will mean that the UK will have the poorest survival figures in Europe.”
Patients who want to use one of the drugs will be forced to pay out of pocket for their health care. The NHS does not allow patients to “top up” their health care coverage, meaning that patients cannot buy private insurance for unapproved drugs.

Cancer patient Andrew Crabb said that he might sell his home to pay for the drug Sutent. “I've only seen him cry twice over this illness—once when he was diagnosed, and then today,” said his wife.

Background: NICE

The National Institute for Health and Clinical Excellence is a semi-independent agency that determines which drugs and treatments are to be used in NHS health care. It makes these decisions based primarily on cost-effectiveness, rather than the effectiveness of treating disease, a philosophy has that generated much controversy.

In a typical NICE decision, it chose to not include lung cancer-drug Tarceva based on its cost. Anne Davis, wife of a man who died of lung cancer in part because he couldn’t get access to Tarceva, said, “No-one should be denied their last hope of treatment and surely a price cannot be put on a person’s life. It’s appalling a decision has been based around cost rather than health benefits.”

This past January, the House of Commons published a report calling for “a change in the law so that NICE can assess not only medical costs and benefits but also the broader social impact of new medicines.” However, the report “steered clear of radical calls for reforms” and the Association of the British Pharmaceutical Industry said that “patients will see little benefit.”

Opinion & Analysis: How can NICE and the NHS best provide care to cancer patients?

The decision has sparked an intense and emotional debate in Britain. The Independent’s Health Editor, Jeremy Laurance, lays out the issues surrounding the decision, providing arguments for both sides.
On one hand, he writes, “Most people will instinctively feel it is inhumane to deny a clinically effective drug to terminally ill cancer patients which could give them even a few months extra of good quality life. However, it is also “the ethical duty of any public health system to spend the available cash to get the best results for patients. Every pound spent on a patient for a less effective treatment is a pound denied to another patient for a more effective treatment.”

Professor Peter Johnson, chief clinician for Cancer Research UK, says that he understands that NICE is forced to make difficult decisions, but believes that there is a “disconnection between the expectations of patients and doctors looking after them, and the decisions that NICE are making.” He calls for an increase in cancer spending, which is half of what the NHS spends on heart disease and just 60 percent of the European average.
Johnson made similar arguments appearing with NICE’s Peter Littlejohns on BBC Radio’s Today. Littlejohns countered that other countries that spend more on cancer drugs have large health care costs and are now looking at adopting a NICE’s methodology to keep costs down. Both men believe that the drug companies deserve some blame for setting prices so high.

Laurance also addressed the issue of drug prices, and was highly critical of the drug companies. He writes, “They are charging astronomical prices for drugs that offer little benefit—in effect, holding a gun to the heads of kidney cancer sufferers and saying to the NHS: ‘Give us the money or we shoot.’”
Most others have been highly critical of NICE and the NHS. Jonathan Waxman, Professor of Oncology at London’s Imperial College, believes that it is time to abolish NICE. “Now with this absurd and arrogant decision on the value of drugs for kidney cancer, NICE has told us that it is absurd, arrogant and unnecessary,” he writes. “Our country should no longer underwrite the costs of NICE, which are currently at £30 million a year, and due to increase. This is a sum that could usefully be spent on providing drugs for cancer patients in a country where we spend less on cancer treatments than on drugs for constipation.”

The Daily Telegraph’s Janet Daley proposes that the NHS allow top-up insurance, a policy that Johnson rejects as an “invidious undermining” of the NHS mission. Daley believes that top-up payments would help make cancer drugs more affordable and provide coverage that is fair for all NHS patients. “Indeed, they would probably be so affordable … that they would rapidly become almost universal, so the notion of a ‘two tier’ system in which only the ‘rich’ could afford extra treatment would disappear.”

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