AN INTERESTING WAY TO LOWER COST

November 24, 2009 — In the United Kingdom, the National Health Service (NHS) has decided not to make 2 more cancer drugs available because of cost. This time, the axe has fallen on sorafenib (Nexavar) for liver cancer and (so far) on bevacizumab (Avastin) for metastatic colorectal cancer.

The use of these drugs for these indications is not cost-effective, according to the National Institute for Health and Clinical Excellence (NICE).

Among other cancer drugs that have been deemed not cost-effective are 4 products for renal cell cancer, which caused an outcry from British oncologists when it was announced last year. The 4 drugs are bevacizumab, sorafenib, sunitinib (Sutent), and temsirolimus (Torisel).

The decision for sorafenib, issued last week, noted that the lowest cost estimate was £52,600 per quality-adjusted life-year (QALY) gained, which is substantially higher than the £30,000 maximum set by NICE for being a "cost-effective use of NHS resources." This decision, a final appraisal, is published in detail on the NICE Web site.

A similar decision was made this week for bevacizumab use in metastatic colorectal cancer. This time the cost of the drug was calculated as £36,000 per QALY. However, this decision is preliminary, and the manufacturer, Roche, has said that it will continue to work with NICE on making the drug available. The company has already offered a scheme to lower the cost of treatment from an initial cost estimate of £62,000 per QALY, according to press reports.

Both of the decisions have sparked headlines about cancer patients being denied life-prolonging drugs. A particularly vocal criticism came from prominent oncologist Karol Sikora, MD, medical director of Cancer Partners UK and a former chief of the World Health Organization Cancer Program. Writing in the Daily Mail online after the sorafenib verdict, he said that, "as an oncologist, I despair of this decision."

"Doctors like me will now be put into a horrible position," he writes.

"It is our ethical duty to tell patients that this drug is one of the most advanced and effective ways of dealing with liver cancer. But then we will have to let their hopes down by explaining that it is not available on the NHS," he continues.

"That is no way to treat people when they are struggling to cope with a killer disease. Without hope, their final days will be all the more agonizing," Dr. Sikora says.

However, this is also the point that one reader hones in on in an online comment that questions spending "vast amounts of money on extending the lives of people who are going to die." Dr. Sikora says that the effects of sorafenib in liver cancer are "striking." Since it has been marketed, it has prolonged the lives of liver cancer patients by an average of 3 months — but he emphasizes that this is only an average, and some patients have not had any gain at all, whereas others have gained 2 to 3 years.

He also points out that the British decision about sorafenib puts it "hopelessly out of step with the rest of Europe," because every other country within the European Union makes the drug available on the state's healthcare or insurance system.

Are Some Cancers Less Fashionable?

"The denial of sorafenib highlights the way some forms of cancer seem to be politically more fashionable than others, with funding skewed in the direction," Dr. Sikora writes.

Breast cancer is the classic example, he says. Its high profile is reflected in the large sums given to screening programs, clinics, drug treatments, and publicity campaigns. He recalls that when trastuzumab (Herceptin) came onto the market, the UK Health Secretary at the time, Patricia Hewitt, announced that it would be available on the NHS even before NICE had concluded its investigation into cost-effectiveness.

But other major killers are badly neglected and attract little political enthusiasm, Dr. Sikora notes, citing liver and lung cancer as examples.

"I passionately believe that all patients should be treated equally," he says, and "should not be subject to vagaries of political fashion."