Cancer drug rationing – dare we speak its name?
By David J. Kerr
I have been an oncologist for thirty years, intimately involved in patient care and in the development of novel anti-cancer therapies. Over that time I have seen the average survival for patients with advanced and metastatic colorectal cancer (my particular field of study) improve from six months without treatment, to around two years with the full panoply of currently available medicines. This has been achieved by a series of incremental steps, extending life by about six months for every increase in the complexity of treatment (from supportive care to single agent, to double agent combination, to doublet chemotherapy plus a biological agent). Although there is a relatively linear relationship between clinical outcome and the number of drugs used in combination, the cost of treatment rises exponentially.
Although drug expenditure accounts for approximately 10% of the total costs of cancer treatment, it seems to dominate the public cancer debate. Usually the National Institute of Clinical Excellence (NICE) is in the firing line for failing to approve some new drug which does not meet the incremental cost-effective criteria by which they judge all innovative medical technologies. More recently, the government’s Cancer Drug Fund, established as an election promise by David Cameron, has found itself in the headlines, mainly due to lobbyists urging the government to continue this fund.
Interestingly, oddly even, I have had a hand in the establishment of both of these outfits. I was a founding Commissioner for Health Improvement, tasked with supporting implementation of NICE policy — remember that NICE was introduced as an antidote to the postcode prescribing prevalent throughout the NHS — and I was Health Adviser to David Cameron and Andrew Lansley in the run up to the last election and supported the creation of the Cancer Drug Fund and the associated commitment to get the UK’s cancer survival figures up among the best in Europe. The initial idea around the Fund was to make anticancer drugs available for rare cancers for which the evidence base underpinning their use would be more difficult to assemble.
This all begs the question: why do cancer drugs cost so much for so relatively little benefit — months rather than years of added life? There is a mystery in this: an element of ‘what the market will bear’; an element of pricing for failure as the majority of anticancer drugs don’t make it to the clinic; an element of spiraling development costs and regulatory bureaucracy. What there is not in common with so many industries is a direct relationship between cost of manufacture and price. When patents expire and the cancer drug becomes generic, meaning that it can be manufactured by anyone with the appropriate environment and skills, the price can reduce overnight by 85%.
How might we make cancer drugs more affordable? I say ‘we’, because it will require a multisectoral approach to solve the problem. The current model of anticancer drug development may be broken and will need industry, academia, funders of research and government to work together to come up with new ways of increasing efficiency and likelihood of success. Colleagues of mine in Oxford have started to promulgate the idea of open access science and how we might apply this to developing better cancer drugs, especially in the early discovery phase, and we are considering how we might match with open access clinical trials linked to real time reporting of side effects and tumour volume.
In the interim, we need to rationalise NICE and the Cancer Drugs Fund. It would be logical to consult widely on the utility of the Fund, on how it has been used, and on its future. It seems illogical and even unfair, that cancer be considered separate from all other diseases. NICE is supposed to provide a unified means of comparing the relative value of interventions across all of medicine, so perhaps the societal debate about the affordability of new drugs should encompass all medical specialties, rather than cancer as a special case.
David Kerr is a Professor of Cancer Medicine at University of Oxford, UK and Adjunct Professor of Medicine, Weill-Cornell College of Medicine, New York, USA. He is one of the editors of Drugs in Cancer Care, a medical text in the Drugs in… series.