No to Abiraterone?
NICE has said no to Abiraterone. Don't rail at NICE. At least, not only at them. They follow rules and those rules restrict NICE's remit.
Cancer Research UK has some interesting things to say on the decision. I particularly agree on their last points, about investment the general public have made over years to support the development of new treatment.
Indeed, I've blogged on this previously.
Abiraterone is used in advanced cancer, a treatment of last resort - palliation, essentially - so we are still not talking of lives saved, but even so..... The potential use of Abiraterone is in the 10,000 men who die each year in the UK from prostate cancer. There are that many in the continuous wave of men alive but 'dying from prostate cancer' at any moment.
Could NICE's decision be challenged on the grounds of indirect ageism?
I don't know, applying such an argument is not a skill of mine but I am happy to be labelled 'muppet' in the attempt. It has to be worth a shot.
I wrote about indirect discrimination in my previous blog post.
The Equality and Human Rights Commission have said: “A business must not do something which has a worse impact on you and on other people who share a particular protected characteristic such as gender than it has on people who do not share that characteristic. [There are 9 protected characteristics. Age is another one...] Unless the business can show that what they have done is objectively justified, this will be what is called indirect discrimination” The Guardian Page 6 Wednesday 25 January 2012 Own Gibson, Olympics Editor.
There might be some let out in the 'objectively justified' comment - but we'll see.
Cancer Research UK's excellent statistical pages show prostate cancer mortality is strongly related to age.
I've lifted these words (slightly rearranged) from there. Remember, 10,000 men a year die from prostate cancer. In the UK between 2007 and 2009, an average 93% of the deaths from prostate cancer were in men aged 65 years and over. Mortality rates increase sharply from the age of 60, reaching a peak at age 85+. Almost a third of prostate cancer deaths occurred in men aged 85 and over in 2007-09.
It is those older men that the NICE decision on Abiraterone quite particularly affects.
And us, indirectly. Why are we making charitable donations to cancer research (the concept, not the charity) on the promise we can help develop new treatments or save lives, or extend lives but, suddenly, what we made is too expensive. Cancer Research UK (the charity not the concept) generates multi million pound legacy income from older people. You think they'd get some benefit, especially as cancer is by and large, a disease of ageing.
NICE's algorithm says no.
What is going on inside the science or inside the commercial considerations or inside policy that flings cancer drugs out of reach at this late stage? If the cost effectiveness equation is so vital, shouldn't it be applied earlier, the research be stopped as soon as it is obvious the results are too expensive to be used. Where does the unsustainable bloat in costs come from? Commercial demands? How much public donation already subsidised Abiraterone? There must be early markers of 'too expensive' that some bright economist or accountant could spot - in the business model, perhaps?
Should cost cutting be factored in much earlier in the drug development process? Spend must be prospectively accrued, after all. How much public donation is 'wasted' developing drugs that then are forced to sit on a shelf?
Is there a model of the ethical/right/ideal Return on Investment in new drugs that would suit the UK policy environment where, unlike other countries (shame on you, USA) we do try and deliver equality of access?
How about Pharma as social enterprise, not big business?
Someone must be thinking these things and have been for years. NICE is not new, nor is its remit nor is this issue.
When is the next big thing being promised in cancer care - personalised medicine - going to turn to bobbins in front of our eyes? Just how likely is it that those brave new medicines will be cheaper than what we have now? I suspect those developments will remain as Abiraterone may well do - right out of reach; out of reach of the NHS and the impoverished pensioners most likely to need most life extending cancer drugs.
How will policy, NICE and public opinion cope with that?