nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Saturday, June 26, 2010

Health Care Reform In Action: Brits Say No To Liver Cancer Drug

Rationing in action:  Great Britain decides the new (and only) liver cancer drug is too expensive to offer to cancer patients.

For Americans who wonder how "scientific" decisions will be made about what treatment choices are considered effective, please go here for the rationale.  I've written before about comparative effectivenesss on multiple occasions (the US term for deciding what works best, based on the views of experts, convened by the government.)  Go here, here, and here for my concerns about how this process will be implemented in the US.

In Britain, the cost-effectiveness organization is the National Institute for Health and Clinical Excellence (NICE).  Supporters of comparative effectiveness in the US insist that the goal is merely to provide expert opinion, and not meant to drive insurance coverage decisions, emphasizing, from the name "comparative effectiveness," that this is all just a comparison and focusing on what works.   However, notice that the title "NICE" says the same, but the Brits are honest enough to admit that it's an organization that makes "monetary cost" versus "value of human life" decisions...and their decisions become government policy.

Here's how that works.  The new drug is expensive, about $5,000 per month.  The average survival from using the drug extends life by, on average, 2.8 months.    Put another way, it would cost the British government $59 a day to pay for that treatment--on average.

I keep saying "on average" because that's part of the flaw in this thinking, and perfectly illustrates my objection to all this.  First, read the official British announcement:
NICE has been unable to recommend sorafenib (Nexavar, Bayer) for treating advanced hepatocellular carcinoma (HCC) because its high cost could not be justified by its marginal benefit.

HCC is a cancer that originates in the liver, not as the result of tumours spreading to the liver from other parts of the body. The only potentially curative treatment for HCC is surgery, but only a small proportion of patients will be eligible for this. Normal life expectancy for these patients is less than 24 months. The trial evidence seen by NICE’s independent advisory committee showed that sorafenib increases survival by an average further 2.8 months, but at a cost of £27,000 per patient. Half of the patients who gained some benefit received less than this amount of additional life.
Three flaws here, two technical and one philosophical:
First flaw:  NICE disingenuously says that "half the patients" who benefit would receive "less than this amount of additional life" (2.8mo).  They fail to give the benefit to the "other" half, who would live some cases a year, maybe?  More?  But since their life is being judged as equivalent to that of the calculated "average" response, those patients who would live considerably longer must suffer the same fate as all--no treatment offered.  And we don't know which ones those potential longer-survivors are.

Second flaw:  Imagine yourself one of these cancer patients.  Surgery is the only cure; if that doesn't work, your alternative is...nothing...because the new denied drug is the only one that's been developed that works at all in liver cancer.  Imagine further that you are one of those patients who would have lived a lot longer from use of the drug.  How does it feel?

And that leads to the third, philosophical  flaw:  analyses like this take human lives and turn them into data, a statistic to be analyzed and manipulated in order to place a "scientific" limit on the cost society should be willing to pay to let you stay alive.  This turns precious human life into an object, like a car, or a refrigerator...

Au contraire, persons should rightly be ends in themselves, not means to an end (cost-control).

Doc D

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