The press reports, again, that patients are being denied life-enhancing drugs to save money. In this case, the issue centres partly from the draft guidance prepared by NICE on Abiraterone, and partly on the impression in Scotland that the drug in question may be partly responsible for the unexpectedly long survival of a convicted murderer.
NICE gets a terrible press, but the work they do is exemplary. The consideration given by the committee is, as ever, consistently careful, thorough and balanced. Their brief was to review
- Overall survival
- Progression-free survival
- Response rate
- Prostate specific antigen (PSA) response
- Adverse effects of treatment, and
- Health-related quality of life.
There is a case for Abiteraterone. It does extend survival by about four months – roughly a third more than without the drug – and it seems to have fewer side effects than the existing drugs. However, the benefits are still limited, and the drug is hugely expensive.
This specific example seems to fall into a category discussed in a debate in the British Medical Journal in 2009 (31st January). Adrian Towse, the director of the Office of Health Economics, argued that the public were generally willing to support payments that were double what NICE was allowing for. The NICE thresholds were typically a cost of £20-30,000 for each QALY (a year of valued life), a figure that has been raised for end of life treatments; the public would support £30-70,000. Against that, James Raftery argued that the thresholds should be lower, because they force health trusts to take resources away from other, more effective treatments. The cost of Abiraterone falls in the region of £53,800 to £63,200 for each QALY.
There is beyond that a common problem: the evidence in this case is almost entirely supplied by the drug’s manufacturer. Manufacturers have only a limited window during which they can market a drug before patents expire; spending time to run all the tests, and in particular to identify the groups best able to benefit, is not always consistent with their financial interests. It is not clear whether Abiraterone does extend survival more than all the alternatives, because the manufacturer has not yet made all the necessary comparisons. If the gaps could be closed, the case for approving the drug would be stronger.