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Discussion on Herceptin

On Sunday 19 February 2006 Huw Edwards interviewed Professor Karol Sikora and Niall Dickson

Please note "BBC Sunday AM" must be credited if any part of this transcript is used.

HUW EDWARDS: Most of you, judging by my mailbag over the past week will now be very familiar with the name of Ann Marie Rogers, and the legal battle that she lost last week.

Mrs. Rogers, who is in the early stages of breast cancer, was told that she didn't have the right to be given the drug Herceptin.

But she and many others are absolutely convinced that it could save her life. So is this the latest example of what some people call a postcode lottery, or is the decision totally justified?

With me are the leading cancer specialists Professor Karol Sikora and Niall Dickson of the Kings Fund, the charity which develops health policy. Gentleman good morning to you both.

KAROL SIKORA: Good morning.

NIALL DICKSON: Good morning.

HUW EDWARDS: Professor, first of all is this a wonder drug, could it save Ann Marie Rogers' life?

KAROL SIKORA: It might. It's got a one in eighteen chance of doing so and that chance is probably acceptable because we have other situations in medicine when we give drugs for that.

The problem is it's very costly. We've got ourselves into a mess as Edwina said earlier on in the programme. The mess is we can't have inequity, we can't have a woman in Stoke on Trent with the same condition getting it and a woman in Swindon not getting it. It's completely unfair. We've got to clear that up.

HUW EDWARDS: How is it cleared up?

KAROL SIKORA: We need to have much crisper regulation, it's taking too long to get these drugs through NICE, the National Institute of Clinical Excellence. It's a very bureaucratic and very robust process but it's taking 18 months often. You can go on the Internet and order the drug from America as soon as it's licensed there. We're in a different age and I think the bureaucracy has to move with the age.

HUW EDWARDS: Niall, it's interesting, I mentioned the mailbag because it's not very scientific but it does give you at least a kind of idea as to what viewers are thinking of. And all of them, almost without exception saying, if this is a good drug, if it gives her even a one in eighteen chance, why on earth isn't she able to partake of it?

NIALL DICKSON: Well I think it's an absolutely fair point that Karol's making about the fact that there is a bureaucratic process that has to be gone through. But in some ways that bureaucratic process is a good thing because it guarantees that drugs are safe and that they're clinically effective.

And indeed the hold-up here is not around NICE, it's around actually getting the drug licensed for that purpose. And the truth is that the drug company itself had not applied to have that drug licensed for people with early stage breast cancer.

So the hold-up in one sense was at the first stage, not at the second stage. NICE looks at clinical effectiveness. It also looks at cost effectiveness. And of course it is, when you look at situations like this you want to say everybody should have everything. But there is a spectrum, and at one end of that spectrum perhaps is a drug which might improve your chances of living for one day and it would cost 1 million.

And we'd all say, no that's nonsense. On the other hand there might be a drug that costs a couple of pence and lets you live for another 20 years and we'd all say that is fine. And between those two things judgements have to be made. And they're difficult judgements and they're likely to become more difficult I think, as drugs change and affect smaller numbers of people.

HUW EDWARDS: One of the implications, Professor, over the last week, rightly or wrongly, you can correct this as you see fit, was that there are pockets of the country where patients at more or less the same stage of the illness, could have got this drug regardless of the licensing issue that Niall's mentioning. Is that true?

KAROL SIKORA: That's the case. Indeed...

HUW EDWARDS: But why is that?

KAROL SIKORA: Because different groups, there are 302 primary care trusts coming to their own conclusion. Everyone's strapped for cash, no doubt about it in the NHS. But some feel this a worthwhile investment, others don't. And every time you get local decision-making you get diversity.

We're going to have a real problem with cancer, this is just one drug, there are three other drugs that are also licensed for other indications in cancer, about the same price, 20,000 - 30,000 a year to take. And over the next five years there'll be even more. Very good news for cancer patients, because this means we'll improve the quality of care.

The difficulty is for the financial system. Now the optimism in the whole thing, we've always managed to succeed. Healthcare systems have always managed to bring in new technology and find the mechanism to deliver it and to pay for it. So, I think Niall and I agree that, you know, we're optimistic that we can sort this out. What we can't have is this blatant unfairness of some women getting and others not.

HUW EDWARDS: I mean, there's a fundamental question Niall isn't there? If it's licensed as you say, and if NICE sorts it out in the way that it's meant to, does it mean that any woman in any part of the country will therefore be able to have this drug?

NIALL DICKSON: It should do. If NICE approve it then it should happen that way. But, it has to be said, we thought that when NICE came along, immediately they said this is a good drug, you should all do it, that they would. But they would, but that assumes that human beings are all going to behave like that, and doctors are human beings. And the answer is that even where NICE has said, we think this is the right drug, you get big variations around the country in the way that doctors are using it.

So they don't always follow that advice. What NICE has succeeded in doing, in some cancer drugs and in other areas, is probably boost the amount that good new drugs are used. And that has been a real benefit that NICE has brought, in spite of the fact that there is this problem that it does take time for them to reach those decisions.

HUW EDWARDS: And let's be clear, we're having this debate in the context of actually, a bit of a funding problem in the NHS. Now, if that's to continue in any sort of way, what are the implications then for drugs like Herceptin?

NIALL DICKSON: Well I think we've probably gone through a period over the last five or six years where I've sort of lost this issue for a while. But it's going to come back again, because all the healthcare systems in the world face it. We've had a lot of extra money pouring into the Health Service over the last seven or so years.

And the amount of extra money that goes in is going to start to dry up. We're still going to have a much better funded healthcare system than we did, but the amounts of extra money coming in is not so great.

And that will once again raise this question about what are we prepared to pay for? Are they cost-effective drugs, and how do we get, as Karol says, a more efficient system so that we are able to deal with these decisions quickly, and we don't get this inequity which we see at the moment.

HUW EDWARDS: You mentioned Edwina earlier who was getting very worked-up about the fact that, according to some reports, some people have even sold their homes in order to pay for this drug. Now that's clearly not something that you condone.

NIALL DICKSON: No.

HUW EDWARDS: But it does reflect the intense emotions, and the desperate plight that some people are in.

KAROL SIKORA: The solution is going to come. It's going to come from the same technology that gave us these drugs. We'll be able to sort out with better diagnostics taking a sample of the cancer, probably within about three to five years, and really predicting which drug is going to work.

So instead of giving it to 18 women we give it to one woman and it's 100% effective. Then the price, the overall costs, come right down. So I think there's going to be more investment now in diagnosing cancer, working out what type it is, what drugs it'll respond to. And that's the way forward.

NIALL DICKSON: But we have to remember that Herceptin for example, only applies to, what, one-fifth of women with breast cancer. It doesn't apply for everybody with breast cancer. And these are not wonder drugs in the sense that they offer a cure. That most of these drugs, they're small advances, significant advances but small advances. So the idea you pop a pill and the whole problem is solved I'm afraid is just not the case.

HUW EDWARDS: Gentlemen, I'm afraid we're out of time but fascinating talking to you both. Niall, Professor Sikora, thank you very much.

INTERVIEW ENDS


NB: this transcript was typed from a recording and not copied from an original script.

Because of the possibility of mis-hearing and the difficulty, in some cases, of identifying individual speakers, the BBC cannot vouch for its accuracy


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