NICE lung cancer U-turn boosts NHS treatment options in England

A combination treatment for some patients with advanced lung cancer will soon be made available on the NHS in England. 

The cocktail – which includes an immunotherapy, a targeted cancer drug and two chemotherapies – had been rejected by the National Institute for Health and Care Excellence (NICE) in February 2019.

But NICE and the company that manufactures the immunotherapy and targeted drug have now reached an agreement on how to best to estimate if the combination treatment was value for money. The company also has discount deals in place with NHS England. 

NICE’s updated recommendation will see the combination available for certain patients in England with non-squamous, non small cell lung cancer that has spread. Patients in Wales and Northern Ireland should also now be able to access the drugs.

Cancer Research UK’s policy manager, Rose Gray, said it was great news that the combination treatment would be made available for patients.

“Lung cancer is the third most common cancer in the UK but survival is lower than many other cancer types – so it’s fantastic that NICE, NHS England and the manufacturer have been able to work together to overcome the challenges that meant the treatment was initially rejected,” she said. 

The combo

The treatment combines four drugs: 

• the immunotherapy atezolizumab (Tecentriq)
• a targeted drug called bevacizumab (Avastin)
•  two chemotherapies: carboplatin (Paraplatin) and paclitaxel (Taxol)  

The drugs in the combination attack the cancer in different ways. 

Atezolizumab is an immunotherapy that blocks a molecule often found in excess on the surface of cancer cells. The molecule, called PD-L1, tells immune cells not to attack the cancer cell. By blocking PD-L1, atezolizumab may unveil cancer cells to the immune system so they can be attacked and destroyed. 

Bevacizumab targets a different molecule called vascular endothelial growth factor (VEGF), that helps cancers to grow blood vessels. By attacking the growth of blood vessels, the drug can stop the cancer from gathering food and oxygen from the blood.

The combination is recommended for patients in two particular groups of adults with non-squamous non small cell lung cancer:

• those whose disease is untreated and has low amounts of PD-L1; and
• those whose cancer is fuelled by one of two particular faulty molecules (EGFR and ALK), and who have previously received therapy targeting these genes, which has failed to stop the cancer growing.

For these groups of patients, treatment is usually a chemotherapy drug called pemetrexed plus one of two other drugs called carboplatin or cisplatin. 

Some patients whose disease is not fuelled by either the EGFR or ALK genes may also already be able to receive an immunotherapy drug in combination with these chemotherapy drugs.

Experts on behalf of NICE said that patients with the above cancer types should only be given the atezolizumab combination if they are fit and healthy enough to tolerate it.

Why the change in decision?

In making its provisional decision in February 2019, NICE said clinical trial evidence did not compare the treatment combination with the current standard of care, so its overall benefits were unknown. 

NICE also disagreed with how the long-term survival of patients with the genetic faults in their cancer was calculated. Because of this, they couldn’t be confident the combination would be cost-effective for the NHS. 

However, after consultation with the company on how the information from a key clinical trial was assessed, NICE agreed a new way of evaluating the treatment. Based on this, NICE decided that the treatment’s cost was under the threshold for how much the NHS would pay. 

The threshold at which the drug could be considered value for money was less strict than normal, because NICE accepted the combination should be considered as “life extending”. This means it will be used in a group of patients with less than 2 years to live on average, and NICE believes the treatment could give most patients an extra 3 months or more to live.

The trial

The study in question included 1,040 patients with non small cell lung cancer, who received one of 3 different combinations of the drugs:  

• bevacizumab, carboplatin and paclitaxel 
• atezolizumab, carboplatin and paclitaxel 
• atezolizumab, bevacizumab, carboplatin and paclitaxel 

The four-drug combination boosted survival. Patients taking it lived around four and a half months longer on average than those taking bevacizumab, carboplatin and paclitaxel. 

“It’s crucial that we find new, effective treatment options for people with this disease, and this drug combination helped some patients on a clinical trial live longer and gave them more time before their disease got worse,” said Grey.

Side effects were slightly worse in the group taking the four drugs. They reported more cases of symptoms such as a rash, loss of appetite and fever. 

Patients were only given atezolizumab and bevacizumab for a maximum of 2 years on the trial. NICE said NHS patients should likewise only be allowed to take these drugs for up to 2 years, or until their cancer gets worse. This is because NICE can’t be sure the drugs are safe or effective after this point.