Cancer drugs and public preferences

Last year the UK government announced the establishment of a £600 million cancer drug fund, to be spent over 3 years. This represents a minuscule amount of money compared to the NHS’s annual budget, which is in excess of £100,000,000,000. However, it demonstrates the government’s preference for expenditure on the treatment of cancer over and above other terminal diseases such as multiple sclerosis (MS). Laura Weir of the MS Society recently spoke out in opposition to this special treatment of cancer. I tend to agree with her view, but am I justified?

Public preferences

In recent years an increasing number of newspaper column inches have been dedicated to criticising NICE for rejecting expensive cancer drugs because they are not deemed cost-effective. If we believe the media then the nation is in outrage about this. The prevailing ‘ideology’ in health economics is to evaluate interventions based on the extent to which they satisfy the preferences of the public. This is done by calculating the number of QALYs gained from an intervention and assigning a monetary value to this gain. The government has now implicitly increased this monetary value for cancer drugs, making them more likely to be deemed cost-effective. If we support the use of public preferences, and if the public support extra spending on cancer, then surely we must in turn also support the fund?

Preference for cancer drugs?

The question is whether society is willing to pay more for a drug that helps cancer patients than for a drug that improves or extends the life of anybody else. Is there really a public preference for spending on cancer drugs? I suspect there is, even if this preference has been reinforced and possibly created by the media. To my knowledge there has not been any significant research in this area. If such research did show a preference then it may justify an increased willingness to pay for cancer drugs.

And what about MS?

As somebody whose life has been affected by MS, but not by cancer, I may be bias. Or not. But I believe that expenditure on drugs should be based on the benefit they provide to an individual. Presumably the preference for cancer drugs, if not completely media-driven, is down to the large number of people affected by the disease. When it comes to the amount of money to be spent at an individual level it seems illogical to allow decisions about this to be guided by prevalence. Let’s remember we are not talking about research here, but the fact that an individual with cancer will be allowed to buy expensive (read: less cost-effective) drugs, while somebody with MS will not. I believe this is wrong. But then, I believe that the use of public preferences is not ideal.

Resources are scarce and for every expenditure there is an opportunity cost. An increase in our willingness to pay for the benefits of cancer drugs, at the extreme, leads to a decrease in spending on all other health care interventions. The cancer drug fund raises many questions, not least the possibility that a QALY may no longer be a QALY but may be a cancer-QALY. I believe this is dangerous territory.

Does this issue leave you questioning public preferences? Should we be prioritising treatment for cancer? Or is this all simply a fabrication by the media?

6 thoughts on “Cancer drugs and public preferences

  1. The issue as I see it is that cancer may have certain characteristics for which the public may value QALYs more than QALYs for other conditions. Or basically “a QALY doesn’t equal a QALY doesn’t equal a QALY”. Is treating 100 bunions (each with a gain of 0.01 QALYs) really equal to treating 1 cancer patient (with a gain of 1 QALY)?

    These characteristics may include severity, end of life, rule of rescue(?) etc. So the response is probably to estimate weights for these characteristics and weight the QALYs (and appropriately reduce the threshold).

    Cancer is a topical and emotive subject, which is probably why the gov’t in their wisdom decided to set up the Cancer Drugs Fund. I don’t agree with it, but we’re very quickly moving away from a QALY = a QALY = a QALY and some more criteria are likely to be included in our cost-effectiveness evaluations in the near future (c.f value based pricing). Also, MS isn’t completely derived of expensive treatments that NICE have approved, beta-interferon and the risk sharing scheme would be a good discussion topic for this blog!

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  2. Professor Werner Brouwer presented on a related subject in Oxford last Monday. The Dutch approach to this decision problem was quite interesting, and (at least to the best of my knowledge) not particularly widely documented. To cut a very long story short, after an extensive period gathering the opinions of the general public and decision makers on this matter, the Dutch came up with a new decision rule. This is best presented graphically with the cost-effectiveness threshold plotted on the y-axis against a measure of disease ‘severity’ on the x-axis. In this case, the measure of severity was “percentage of remaining life years lost if left untreated”. The resulting decision rule is low at low percentages, and increases as severity rises, to the point where at the 80-90% level, the cost-effectiveness threshold reaches 6 figures (in €/£).

    This approach isn’t without some notable flaws, but was (is?) an interesting alternative take on a complex decision problem.

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    1. Interesting, but it does seem a bit crazy. In our language this methodology could, theoretically, justify expenditure of £1,000,000/QALY… or more!

      I think the methodology is a bit backwards. Does it take no account of an individual’s quality of life? If so then there would have to be a subsequent investigation of society’s willingness to trade length of life for quality of life at different points on this graph… and then we end up back at QALYs. Surely it makes more sense to estimate the relationship between society’s willingness to pay for a QALY and the life expectancy of the individual, and figure out a new decision rule based upon this.

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