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A Tale of three drugs

May 11, 2007

Non-medics may care not to read this!

Dr Crippen has THIS post today about the lack of availability of Tarceva (erlotinib), a drug about which he has strong views and has previously posted. I think it may be helpful to consider the case of this drug in a little more detail. Tarceva is a drug which is licensed for the treatment of lung cancer after previous chemotherapy. It is no available on the NHS as it is deemed by NICE not to be cost-effective (though interestingly it is cost-effective in scotland-work that one out if you can!)

There are 2 other drugs licensed in this situation, namely docetaxel and pemetrexed. Only docetaxel is available in the NHS. The following are 3 graphs showing the survival figures for 1) tarceva vs placebo, 2) docetaxel vs supportive care and 3) docetaxel vs pemetrexed

1)

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2)

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3)

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They show (to me, anyway) that both docetaxel and tarceva give a survival advantage over supportive care alone, amounting to an approximately 10% absolute survival advantage at 1 year. The third graph shows that pemetrexed is as effective as docetaxel.

The costs of these drugs (approximately) are as follows:

Tarceva £1,800 per month (average course will be around 3 months, may go up to 18 months)

Docetaxel £6600 per course

Pemetrexed £8000 per course

These drugs have different side effects, different risks, one may be more suitable for one patient than another. I believe they all have a role, and in the private sector I am able to discuss with patients the pros and cons of each and come to a decision as to which is better for an individual patient. Why am I not allowed to do the same in the NHS, where the choice is docetaxel or nothing? Just because it is the cheapest does not make it the best choice. Indeed for a patient who is likely to have side effects from docetaxel, tarceva may be more cost-effective. The only people who will be on the treatment fo more than 6 months will be those who are benefiting, and in those patients the drug is cost-effective. The people in the best position to make these decisions are the oncologist and the patient, NOT the DoH. If they had their way, oncology could be practised by automatons.

Now, that said there has to be rationing in the NHS. There will be drugs and treatments that we cannot afford. I feel, however that if these treatments are available in every other developed country but not the UK, then we have set the cost limit too low, and this is reflected in the fact that our cancer outcomes are amongst the worst in the developed world. It might be that we decide that this is acceptable and we will not devote resources to treating cancer as it is not cost-effective. If so, I will look for a new job.

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12 comments

  1. Hi Mens Sana,
    I seem to recall in a post not many Moons ago, when despite your 6 month prognosis for a patient, it was another 18 months before he succumbed.

    What does that do to the real ‘value’ relevance or reliability of the above graphs.

    After all statistically all people will DIE whether they have cancer or not. Funny how we have one in three chances of developing ‘cancer’ – of course I’d prefer to think I have two in three of NOT.

    Nut hey that does not mean there are not people in need of dentistry who cannot ‘afford’ dentistry.
    Whether it be £1200 a year or even £1200 a month.


  2. Exactly. He was one of the 10% who are still there at the end of the graph. And he wouldn’t have been without treatment. These drugs don’t provide great benefits for most people, but they do for some. And we can’t predict accurately who.

    That doesn’t say the graphs have no value, but it does say you have to understand what they represent, and particularly that something which improves average prognosis by 2 months may improve some people’s prognosis by 2 years


  3. You sacre me, by confirming everything i ever thought about the NHS being true. There really is no gaurentee we will get the appropriate treatment for our various aliments. i’m in the US at the moement where it is equally as scary, walking into a doctors office or hospital you cannot miss all the different payments options they accept, in fact it si the first thing they ask – how are you going to pay? Makes me greatful for the NHS is nsome ways…….
    Great blog, i loved your description of yourself, considering where you work i’d love your feedback on my blog, apparantly doctors only second to publicans in alcohol related deaths………


  4. What you say makes perfect sense, we are becoming the third world when it comes to providing health care and medicines.


  5. That should have read “third world country”.
    Thank heavens for leaches and maggots – though not for this treatment, of course.


  6. maggots good. Not so sure about leeches!


  7. Took your advice and skipped it M Sana . No word about your imminent battle with Brown who , he says , will be wanting a tad more work from you ?


  8. Well NM no word yet. I doubt he will smile on my cosy deal with the local lamborghini franchise. But all is not lost- I have a plan to rebrand myself as a community health delivery quality and value consultant. Cunning use of the word community will blur the boundary of when I am actually supposed to be in the hospital and the other words will, if current policy is anything to go by, add to my salary in inverse proportion to their usefulness.

    I may even end up on the prime minister’s delivery unit. Perhaps I might get ushered into the presence of the great man himself. I shall rename myself von Stauffenberg. Ask not what your country can do for you…


  9. Yes very funny Men S butwhat about being picked on so Gordo can look like he cares about tax payers .( Which he clearly does not )


  10. In 1977 you had a one-in-four chance of being alive ten years after a cancer diagnosis; now, we are told, it’s down to one-in-two. That’s not bad.

    The law of diminishing returns surely applies. When do you call a halt? If it costs £100,000 to gain a single life-year is it worth it?

    In my line of work the old Pareto analysis applies. It takes 20% of the cost / effort to achieve 80% of the objectives. One of my first conversations with clients usually goes something like “Do you want 100% for £5m or 87% for £2m?”. When you’re talking about a human life it’s different, of course. But who wants to live for ever?


  11. OK NM on a serious note I think it is highly likely that Gordon will try and change the terms of some of the contracts negotiated. I think he will find it difficult to make rapid progress, but the feeling is that he is going to start by reallocating QoF payments to GPs in order to reward those who provide an out of hours service.

    I think he will find it difficult to attack hospital consultants, as the main reason most of us do not work harder is that our Trusts do not want us to as they cannot afford to pay us. What he is therefore likely to try and do is freeze consultant pay at current levels, or as close as possible. This is likely to bring him into conflict with the independent DDRB, our pay review body.

    Rather alarmingly the one area where they are trying to save money is in the training budgets, but it is possible that they would require consultants to fund all their own training courses etc. Not necessarily a bad thing but it would require the revenue to treat them as tax-deductible expense, which currently is not the case. In the end, I think this might save around 0.5% of the consultant salary budget, so may not be worth the ill-will

    In the end, although there will be a lot of anti-doctor spin, they will need to find a way of bringing the medical profession with them, and as I have previously said there need to be carrots as well as sticks for this to work. Although in an ideal world one might say stuff the lot of them, pay them nothing and let the market find their true salary, we are where we are, and I think it is highly unlikely that revolutionary change will be proposed


  12. Raedwald you are right. there has to be a limit. I have no problem with that at all. Its just that our limit seems to be much less than everyone else’s. Is a year of an Englishman’s life worth less than that of a Scot, or perish the thought a Frenchie? At the moment we are on a par with Romania



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