One of the sessions at this year’s NCRI conference was on the theme of ‘The cost of cancer care’ and included those hotly debated topics of drug approval by NICE and regional variations in cancer spend (aka the ‘postcode lottery‘).
So it was unsurprising that the lecture theatre was packed to the rafters, with some people resorting to perching on the steps.
The Government’s view
Professor Mike Richards, National Cancer Director, kicked off the session. He acknowledged that the UK spends less on healthcare as a whole than many other European countries. On top of this, we spend proportionally less on cancer care than many of our EU counterparts.
According to the latest figures, around 5 per cent of the NHS spend is on cancer, equating to around £76 per head each year in England (around £4.5 billion a year in total). In comparison, France and Germany spend over £120 per head on cancer care. Even if we include the amount spent in this country through private care and by voluntary organisations, the figure is still only around £90-100 per head – well short of our European neighbours.
Clearly there is a need to increase spend in the NHS on cancer – particularly when the demographics and new advances in cancer drugs are taken into account. As the population ages, cancer is getting more common – Professor Richards commented that the incidence of the disease is increasing at a rate of around 1.5 per cent each year. This means there will inevitably be more people needing cancer care services.
And with great strides in cancer research, many new drugs and diagnostic tests are coming through – offering new hope to people touched by cancer – but at a price. On top of this, the NHS needs to consider the increasing cost of follow up care for cancer survivors (‘survivorship care’) – as more and more people survive cancer.
So cancer care costs are certain to increase in the future, and these will need to be met through boosting spending and efficiency in the NHS.
Professor Richards believes the NHS can indeed make cost savings. For example, currently over a quarter of the total spend on cancer care in this country goes on ‘in-patient costs’ – people staying in hospital – and we have more in-patient cancer cases per capita than many other countries, including the USA.
He conceded that this is partly due to delays and inefficiencies in hospitals, such as people waiting several days for tests that could have been carried out much more quickly.
The role of NICE
Even with improved efficiency and increased spending, some tough and inevitably controversial, decisions will always have to be made within the NHS on how and where to spend its money. And this is where the National Institute for Health and Clinical Excellence (NICE) comes in, as explained by Andrew Dillon, its Chief Executive.
Perhaps NICE’s highest profile remit is to appraise newly licensed cancer drugs and decide if they should be made available to patients on the NHS. Some might say it does this difficult job well, others vigorously disagree and are angered by NICE’s decisions.
(As regular blog readers will know, Cancer Research UK has submitted a full response to NICE in the wake of their recent decision to reject four drugs for advanced kidney cancer)
It is clear that NICE has a challenging remit, having to make the best possible use of very limited resources. In an ideal world, every new drug that adds any survival benefit, even an extra day of life, would be made available to everyone who needs it. But obviously this isn’t realistic. The NHS doesn’t have infinite resources and, even with increased investment, will always be restrained by cash.
As Andrew Dillon pointed out, between April 2004 and August 2008, NICE has carried out 39 cancer appraisals, with 15 treatments being fully recommended, 15 being given limited use approval and 5 being rejected (4 couldn’t be recommended as the drug companies submitted ‘insufficient evidence’) – possibly a different picture to what some people might have expected.
It’s certainly the case that the drug rejections by NICE tend to grab more media attention, giving a rather distorted view. But it’s also true that improvements need to be made within NICE and the NHS if we are to beat cancer.
The delays seen in the past with the NICE approval process are totally unacceptable, with the availability of some drugs like Temodal being held up by a couple of years in this country. One of the reasons for this has apparently been the delay by the Department of Health in referring drugs to NICE for appraisal.
NICE say they have finally cracked this: drugs will now be referred for appraisal 15 months upstream of marketing authorisation, which means NICE should be able to make a decision within 12 weeks after launch of the drug.
Tackling the ‘postcode lottery’
Another major issue that hasn’t yet been addressed is that of the postcode lottery. Even if drugs are approved by NICE, they may not be made available to all patients, as the decision over whether to pay for them will depend on their local health trust. Official figures released in November 2007 showed that some primary care trusts (PCTs) spend three times more on patients than others. This shouldn’t be the case – it should be mandatory that PCTs provide all NICE-approved drugs, and that patients have equal access to treatment irrespective of where they live.
It’s also clear that NICE needs to work more closely with the research community, particularly during the planning of clinical studies. Andrew Dillon, in his talk, expressed a desire and commitment to do this – time will tell whether they deliver on this.
The pharmaceutical industry
Richard Tiner, Medical Director of the Association of the British Pharmaceutical Industry (ABPI) also spoke at the session, from the perspective of the drug companies.
He defended the high cost of new cancer drugs, explaining that they typically cost around £500 million to produce – from research through to market. It’s also a long process, often taking 10 to 12 years.
And he also explained that it’s a high-risk business with a large ‘fallout rate’. For every 5,000 potential agents studied in the lab, only around 8-15 drugs typically make it into clinical trials, and only one of these will ultimately go into the market.
So the price tag of a drug ‘on the shelf’ doesn’t just reflect the cost of developing that drug, but it also has to cover the cost of these failed drugs too.
Despite this, he added that the current drug ‘pipeline’ was in rude health, with there being about 2210 new drugs currently in trials.
The patient perspective
Jessica Corner, Chief Clinician at Macmillan, provided a different and very important alternative perspective on the cost of cancer care. She talked about the current research into the cost of cancer to patients, due to things like loss of earnings, travel costs for treatment, out of pocket expenses, and long-term financial consequences.
She said that much more research is needed to look at financial issues for patients – and more strategies implemented, such as less-frequent chemotherapy (meaning fewer trips to hospital), to reduce this financial burden.
And there’s another field of research that could make a huge difference to the NHS’s resources in the future. A hot topic at the conference was so-called biomarkers. These are essentially protein or DNA tags on cancer cells, or in the bloodstream, that can help to guide cancer care, whether it be predicting response to a particular treatment or aiding diagnosis.
At the moment, there is relatively little tailoring of treatments to cancer patients based on the ‘molecular signature’ of their own tumour.
But if we can discover more biomarkers for indicating which patients are likely to respond to a particular drug – then we can avoid giving expensive drugs to people that won’t benefit from them. This will prevent patients suffering unnecessary side effects, enable them to be offered an alternative treatment from the outset, if available, and avoid unnecessary expense.
One good example is Herceptin, thought to cost the NHS over £100m each year. At the moment, it is offered to all women with breast cancer carrying the HER2 protein on their cancer cells. But some of these women won’t get any benefit, due to genetic variations in their tumours.
If biomarkers could be found to accurately distinguish between women who will benefit and those who would be better off on another treatment, this could free up valuable funds to pay for other drugs.
In summary, there are many challenges facing the NHS over the next few decades to meet the increasing cost of cancer care.
There will need to be more spending, more efficiency in the NHS and drug approval system, and more equality in treatment across the UK. And on-going close collaboration between all those involved in cancer research and care delivery is essential.
Helen is Cancer Research UK’s Head of Science Information