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The high cost of publicly funded cancer drugs

Patients with prostate cancer in England and Wales will now have early access to abiraterone, a drug which can delay the need for chemotherapy. The drug previously cost £3,000 a month, and was not considered “cost-effective” for the NHS until cancers were more advanced – even though patients in Scotland had access to it.

The U-turn comes after a lower price was agreed with the manufacturer Janssen – making abiraterone affordable for widespread use. Janssen is also said to have submitted fresh data about the drug’s effectiveness to the National Institute for Health and Care Excellence (NICE), which decides which drugs and treatments are available on the NHS in England and Wales.

This change in price now means that abiraterone can be given to prostate cancer patients who have mild symptoms but evidence of the disease spreading. The drug will also be used in patients who have not previously responded to hormone therapy and have not undergone radiotherapy.

While this new widespread use of the drug is great news for cancer patients, why has it taken so long to get things to this point? It does not seem entirely clear what this new data is, or why the current, published data was considered to be insufficient. And it’s not the first time decisions on life-saving drugs have come into question.

Dying for treatment

There are a wide and generally effective range of treatment options for prostate cancer available. The main one is hormone therapy, which is aimed at blocking androgen (testosterone) production.

The rationale for this treatment is that most prostate tumours, especially in the earlier stages of the disease, require androgens for their continued growth and survival, in much the same way that some breast cancers are dependent on oestrogen.

Prostate Cancer kills one man every hour in the UK.

The original treatment for depriving prostate tumours of androgen was the removal of the testicles, giving rise to the delightful term “castration resistant prostate cancer”.

Abiraterone delays the need for chemotherapy by helping to overcome the problem of “castration resistant tumours” – where the cancer cells become more and more sensitive to androgen in response to its reduced levels after hormone therapy.

Castration was subsequently replaced with drug-based therapy, with abiraterone developed in the early 1990s by scientists at Cancer Research UK’s Centre for Cancer Therapeutics – using money donated by cancer survivors, the families of cancer patients, and numerous other individuals and organisations.

And yet the final product has until recently been prohibitively expensive, to the point where thousands of men may have missed out on its potential benefits, and it has severely strained NHS budgets.

Drug of choice

Abiraterone has long been considered to be one of the most effective treatments for prostate cancer as it almost completely blocks testosterone production. This has been supported by a number of large clinical trials, including one that recruited 1,088 men and revealed that abiraterone increased the average time taken for prostate cancer to spread from eight months to 16.5 months.

Despite this, NICE refused to approve the use of abiraterone for prostate cancer on the grounds that its cost was not justified by its proven clinical benefits.

While NICE have now reversed this decision, it still doesn’t take away from the fact that for so long, so many men have been unable to access an effective treatment for prostate cancer, which could have helped to delay the spread of the disease.

One in seven men will be diagnosed with prostate cancer during their lifetime. Image Point Fr/Shutterstock

Of course, hormone therapy is not without side effects – it can (and usually does) lead to varying degrees of feminisation, alongside erection problems, hot flushes and breast tenderness. However, these side effects are generally far less severe than those associated with therapies used when tumours fail to respond to hormone treatment.

This type of treatment includes conventional chemotherapy with cytotoxic drugs that are generally designed to selectively kill rapidly dividing cells.

Many normal adult cells also need to divide quickly though – for example those involved in replacing the lining of the gut or in generating new blood cells – meaning this type of chemotherapy can have a broad and significant range of unpleasant side effects including hair loss, mouth ulcers, nausea and vomiting as well as increased chance of infection from the drop in white blood cells.

When you consider the debilitating side effects associated with chemotherapy, and the fact that prostate cancer is the most common male-specific cancer with around 35,000 new cases and about 10,000 deaths every year in the UK, the fact that drug therapy is withheld in treatment is very concerning.

But abiraterone is not the first anti-cancer drug to prove prohibitively expensive. Consider the small sum of £90,000 required for a course of the breast cancer drug Kadcyla. Or the £24,000 cost per patient per year for another breast cancer drug, lapatinib.

Then there is also growing disquiet about the regional differences in the cost of drugs with lapatinib costing considerably less in a number of other countries.

Questions need to be asked around drug costs and accessibility across the whole of the UK. Because although abiraterone isn’t the first high-cost cancer drug, sadly it won’t be the last.

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