Evidence Submission (Co-authored narrative): The Cancer Drug Fund, radiotherapy and cancer survival
Following its inclusion in the Conservative party manifesto for the last general election 1 and a commitment in the subsequent coalition government agreement 2, in July 2010 the health white paper announced the establishment of a Cancer Drug Fund designed to improve access to drugs not yet approved for use on the NHS 3. The Cancer Drug Fund then began on an interim basis in October with a fund of £50million before coming fully into effect in April 2011 with £200million.
In the same documents, and in the subsequent NHS Outcomes Framework 4 and NHS Improving Outcomes Strategy for Cancer 5, the government also stressed its intention to focus the NHS on improving health outcomes, and made particular commitments to improve our cancer survival rates relative to other countries. A recently published King’s Fund report, “How to improve cancer survival”, reviewed the evidence for where the greatest opportunities are for achieving this goal, and argued that the Cancer Drugs Fund will have ‘very limited’ impact on improving cancers survival rates. Instead, diagnosing more cancer at an earlier stage and improving access to surgery and radiotherapy – treatments which receive far less media attention – is more likely to help to close the gap with the outcomes achieved in other countries 6.
Surgery, radiotherapy and cancer drugs (both chemotherapy and other drug treatments such as hormonal therapies) do all contribute to cancer survival. New cancer drugs have contributed to improving outcomes for many cancers, including breast cancer, many childhood cancers, testicular cancer and Hodgkin’s disease. There is also evidence that the UK’s uptake of some cancer drugs has been low. Usage of recently launched cancer drugs was less than half the international average, although use of hormonal agents, such as the breast cancer drugs tamoxifen and anastrozole, was high 7. But the relative contribution of cancer drugs to overall survival is small. The evidence from clinical trials on the impact of cancer drugs on survival in Australia and the USA for 22 adult cancers found that the overall contribution of chemotherapy to five-year survival was just over 2 per cent 8. Two successive reports from the Karolinska Institute in Sweden have examined cancer survival and mortality across 19 countries in Europe in the light of availability of cancer drugs. The reports did conclude that access to new drugs was linked to survival 9; 10. However, these studies have been heavily criticised for over-estimating relative survival and using drug data from a more recent period that the cancer outcomes data 11.
The drugs that the Cancer Drug Fund is making more available will not make a significant contribution to cancer survival. Drugs such as Sunitinib, which is used for kidney cancer, translate into an improved survival for one individual patient of about three months. It is certainly a useful drug, far better than what was previously available, but it can be very toxic (some of its side-effects can be life-threatening) so, with an average 18-month course of Sunitinib costing the taxpayer £60,000, a dispassionate cost-benefit analysis could reasonably question whether that £60,000 be used better elsewhere in oncology, or even perhaps in other parts of the NHS which have not had the prominence of cancer medicine in recent years?
Both surgery and radiotherapy make a significantly greater contribution to overall cancer survival. The optimal proportion of patients with cancer that should receive radiotherapy varies by tumour type and stage, but overall it is thought to be around 52 per cent 12. In 2005, the radiotherapy access rate in England was only 38.2 per cent 13. Work is underway to increase England’s radiotherapy capacity and expand the use of complex radiotherapy treatments 14, but there remains significant scope to improve outcomes by increasing access to radiotherapy.
One author (PK) and colleagues have previously suggested that the £200 million instead be used as a ‘cancer treatment fund’, as currently it fails to consider any investment in non-drug therapies such as new techniques in radiotherapy and surgery, when, in terms of outcomes, surgery, and particularly radiotherapy are far more cost effective than new drugs. For example, providing an incentive of £500 per patient to ensure that each of the 16,000 patients it is estimated would benefit annually from Intensity Modulated Radiotherapy (IMRT) received such treatment would cost only £4million, or eight per cent of the fund. This intervention would ensure that thousands of patients would benefit from having the optimal radiotherapy for their cancer, with the likelihood of increased cure rates, whereas the same amount of money invested in cancer drugs would treat far fewer patients, without any potential to improve cure rates, as, at best, most of those patients lives will be extended by just a few months.
Governments necessarily make trade-offs between competing priorities and goals in policy, and health policy is far from immune from decisions based more in politics than in evidence. But as funding pressures bite in the NHS we need to contemplate re-prioritization of spending in health care. Ultimately, the most productive investments in the NHS will be those that prevent illness, reduce demand, or allow diseases to present at a stage where they can be effectively treated, which not only improves outcomes but also would lead to reductions in costs of investigations and treatments.The Cancer Drug Fund will extend the life of some cancer patients, in a few cases for a long time, and will save some lives. But the government must accept that choosing to invest this additional funding specifically in cancer drugs will mean it will not support its stated overall goal to improve cancer survival.
Parts of this article first appeared in Cancer Nursing Practice in March 2011,© RCN Publishing Company Limited
References
1 Conservative Party (2010). Invitation to join the government of Britain: The Conservative manifesto 2010. London: The Conservative Party.
2 HM Government (2010). The Coalition: our programme for government. London: The Cabinet Office.
3 Department of Health (2010a). Equity and excellence: Liberating the NHS. London: The Stationery Office.
4 Department of Health (2010b). Transparency in Outcomes: NHS outcomes framework 2011/12. London: Department of Health.
5 Department of Health (2011). Improving Outcomes: A strategy for cancer. London: Department of Health.
6 Foot C and Harrison T (2011) How to improve cancer survival: Explaining England’s relatively poor rates. London: The King’s Fund.
7 Richards MA (2010). Extent and Causes of International Variations in Drug Usage: A report for the Secretary of State for Health by Professor Sir Mike Richards CBE. London: The Central Office of Information.
8 Morgan G, Wardy R, Barton M (2004). ‘The contribution of cytotoxic chemotherapy to 5-year survival in adult malignancies’. Clinical Oncology, vol 16, no 8, pp 549–60.
9 Wilking N, Jönsson B (2005). A Pan-European Comparison Regarding Patient Access to Cancer Drugs. Stockholm: Karolinska Institutet and Stockholm School of Economics.
10 Jönsson B, Wilking N (2007). ‘Volume 18, supplement 3, a global comparison regarding patient access to cancer drugs’. Annals of Oncology, vol 19, no 7, pp 1–75.
11 Coleman MP (2007). ‘Not credible: a subversion of science by the pharmaceutical industry. Commentary on “A global comparison regarding patient access to cancer drugs (Ann Oncol 2007; 18 suppl 3: pp 1–75)”’. Annals of Oncology, vol 18, no 9, pp 1433–5.
12 Delaney G, Jacob S, Featherstone C, Barton M (2005). ‘The role of radiotherapy in the treatment of cancer: estimating the optimal utilization from a review of evidence-based clinical guidelines’. Cancer, vol 104, no 6, pp 1129–37.
13 Williams MV, Summers ET, Drinkwater K, Barrett A (2007). ‘Radiotherapy dose fractionation, access and waiting times in the countries of the UK in 2005’. Clinical Oncology, vol 19, no 5, pp 273–86.
14 Department of Health (2007). Radiotherapy: Developing a world class service for England. Report to ministers from National Radiotherapy Advisory Group. London: Department of Health.
Evidence submission by:
Dr Peter Kirkbride
National Clinical Advisor, Radiotherapy
Consultant Clinical Oncologist, Weston Park Hospital, Sheffield
Catherine Foot
Senior Fellow
The King’s Fund
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