5 Comments

• g 12th Mar '11 - 9:29am

  The alt med stuff is a concern, especially with Lansley’s plans to allow GPs and patients to choose treatments which currently PCTs would prevent (there are a handful of rogue GPs offering routine quackery, this will rise). But the cancer drugs fund sucks money away from proven treatments into newer treatments that lack a robust evidence base, are expensive and for which vested interests are lobbying for. EG most rare cancers charities are funded wholly by pharma companies…

• DunKhan 12th Mar '11 - 11:59am

  @g

  I agree with the first half of your post, alternative medicine on the NHS just sucks money away from real treatments. However, I do disagree with the second half of your post, particularly with regards to cancers. If you don’t feel like reading my next few paragraphs then just substitute in “they’re better but more expensive”.

  My background is in the biological sciences and I have studied cancer biology, and will be going on to study it further given a little luck in the next few weeks. Put bluntly, going for “proven” old treatments is a false economy, because the new generation of cancer drugs are objectively a lot better, though certainly a lot more expensive. This is because chemotherapy drugs are DNA damaging agents and act broadly – the assumption in their use in cancer treatment is that cancer cells divide quicker than normal cells and that therefore chemotherapy will affect the cancer proportionately more.

  Generally this is true but the chemotherapy obviously has huge side-effects (not least because it also goes to town on rapidly dividing cells that happen to not be cancerous) as it is so broad-based and moreover it is just not very effective against some cancers which happen to not divide very quickly or which have developed resistance. Some specific cancers can even respond to chemotherapy by dividing more quickly (I think explaining why would be beyond the scope of this already massive post though!).

  The newer therapies don’t have as much history of clinical use (on account of them being new) but they’ve passed the exact same trials process and so are pretty heavily evidenced – a huge amount of very promising potential drugs are shelved in clinical trials. The newer therapies also tend to be more targeted and therefore more effective and with less side effects. They are on the forefront of development of personalised medicine. They are, however, very expensive, and with good reason.

  To use a well known example trastuzumab (aka herceptin) is a very expensive, quite new cancer treatment that makes the HER2 subtype of breast cancer (previously very difficult to treat and not uncommon) quite trivial to treat. It’s hideously expensive on the grounds that it’s a monoclonal antibody (difficult and expensive to produce). It’s so specific for the same reason. Every cancer is different and some simply can’t be treated with the older, cheaper treatments.

  This is an oversimplification as there are definitely “old” cancer drugs which aren’t chemotherapies, some of which are very good for specific cancers (Glivek, for instance – look it up if you’re interested) and there are new drugs which are just small molecules which can be very effective and quite cheap.

  But your fundamental point is that these new drugs are expensive and less well evidenced than the older ones. Not all of them are expensive, those that are expensive are expensive for a good reason, they’re perfectly well evidenced and when they’re made they’re not just doing the same thing, they’re targeting cancers which are otherwise pretty much untreatable. Some people will be fine on the old ones, some will be fine on the new ones. In principle, they should all have what they need. When money comes into it hard decisions have to be made but it is very short sighted to completely discourage use of these newer drugs, quite a lot of people have no hope of survival without them.

  I think I’ve written far too much already so I won’t go into rare diseases – but rare diseases are a completely different kettle of fish medically, economically and legislatively to more common ones and operate in their own little world. I’d suggest researching thoroughly this area before treading into it, it’s easy to paint a completely false negative image here if you’re not working with the full set of facts. There are things to be wary about in the pharmaceutical industry and there are areas where they can be downright unethical but you haven’t hit on any of those areas in your post.

• g 12th Mar '11 - 1:09pm

  @DunKhan

  Thanks for the at length reply.

  I admit my second point should have been argued with more subtlety. Just to be clear I’m not approaching this from a position that regards pharma as inherently immoral. After all this is an industry that seeks to profit from improving human lives, which places it on a completely different moral plane than the arms, tobacco or alcohol industries with which its often compared. Pharma is an industry where the interests of shareholders generally align with the interests of society. This does not mean however that distortions in the market, such as the cancer drugs fund, are of benefit to both. This is effectively a discrete pot of money put out to tender to a subset of pharma interests.

  In addition to this the best interests of cancer patients may not align with the best interests of a health service subjected to inevitable budget squeezing and political tampering. The creation of a cancer drugs fund (as supported by all political parties) politicises treatment and effectively sets cancer patients against those suffering from other diseases. It runs a risk of creating the cancer voter vs the dementia voter vs heart disease voter and so on. I have no objection to policy identifying areas of key concern for medical research but as much as is possible this should be a process of expert opinion and public consultation rather than headline grabbing political grandstanding.

  I also think you underestimate the extent to which longer term follow up studies of patients can influence our understanding of cost/benefit ratios.

  That said, I think the rapid reduction in costs of genome sequencing, and the aggressive development of technologies allowing the rapid and relatively cheap sequencing of cell lines, and ultimately biopsy samples, to establish individualised cancer treatment will revolutionise cancer care. Of which I am hugely enthusiastic about.

• DunKhan 12th Mar '11 - 5:36pm

  @g

  You seem to have more background than I assumed, so sorry if my tone sounded patronising in any way in my previous post! I’m broadly in agreement with your views on the pharmaceutical industry – they’re not perfect at all (certainly I’d prefer more of their profit to be driven to R&D than marketing!) but they ultimately provide an extremely valuable service.

  I’m not truly convinced that calling this a distortion of the market is really justified, particularly as it’s quite a judgmental term. Orphan drug legislation distorts the market but it’s the only way in which rare diseases end up with treatments, it doesn’t warrant the judgment implicit in that kind of tag. Although I’d hardly put this fund on the same kind of earth-shattering league as orphan drug legislation at all but it does compensate for the higher cost of the next generation of cancer drugs and gives oncology in the NHS a bit of a boost regarding keeping up to date.

  I’m not sure I can agree with all of what you say on your third paragraph, a lot of it seems to me to just be a slippery slope argument, which I dislike as everything is stupid if you take it to its logical extreme. There’d be less money for people suffering from other diseases, yes but as far as I’m aware newer cancer drugs are far more expensive than newer drugs for treating CV disease and certainly moreso than newer drugs for treating dementia (so much as there are any). I’m not convinced that politicians are going to be rushing to make too many of these kinds of funds anyway. I’d agree that the NHS budget should be handled by experts rather than politicians with no medical or scientific backing but as it isn’t at the moment I’m hardly going to object to a good thing because it doesn’t come from my ideal set up for the NHS. That’d be taking idealism too far.

  I’m fully aware that longer term follow ups can increase understanding but I would not say that it as a matter of course fundamentally changes our understanding of how the drug works and what it acts on. Certainly, as you said, it can improve our understanding of how much benefit you get from the cost and also the fine tuning of the treatment (doses, what else to give alongside the drug and so on). However, fundamentally some drug treatments don’t work on some cancers and no amount of refining the treatment or reducing of costs will change that. At the end of the day you need more drugs to treat more kinds of cancer and the UK has been lagging behind in providing them. You can’t afford all of them, certainly, but providing more money for an area of treatment which is important and which is expensive can certainly help.

  I’d definitely agree that genome sequencing going down in price is a very, very good thing for cancer treatment though. I think the cheapest second generation genome sequencings are a bit over $10,000 now so hopefully not too long to go. Hopefully the third generation techniques will be able to bring it down even further.

• Old Codger Chris 12th Mar '11 - 5:41pm

  The next time anyone accuses me of being an airy-fairy liberal, I’ll point them in the direction of this Tory MP. Is he a friend of Cherie Blair?

  Although this is good for a laugh, there is a serious side when desperate people are conned by unregulated charlaterns.