Herceptin, health & politics

Was Pharmac’s decision to not fund 12 month courses of herceptin based on clinical evidence or financial necessity?

Women’s Health Action Trust director Jo Fitzpatrick accepts it was clinical: 

[she] “reluctantly” spoke out yesterday in support of the decision, “because of concern at the high level of public misunderstanding about the drug and its effects”.

“Herceptin is promoted as the magic bullet for early breast cancer treatment,” she said. “People used to think – and many still do – that Her-2 positive breast cancer can and will be cured by Herceptin.

“We wish that was true but the evidence just isn’t there and people need to know that. At its best, 87 women in every 100 taking Herceptin get no benefit from the drug at all and may be harmed by it.”

And:

District health boards’ spokesman Murray Georgel said the lack of convincing evidence for 12-month treatments meant the decision was one “DHBs can understand”.

“In that context, and given the ability of DHBs to improve health through other interventions, it would have been concerning if Pharmac had come to DHBs and asked that the 12-month treatment be funded.”

But:

Other groups were scathing of the decision. Breast Cancer Aotearoa Coalition chairwoman Libby Burgess called it “a cruel blow for women and their families”.

She said the drug was “life-saving”, and Pharmac’s decision was “shameful” and “simply inhumane”.

Comments on my previous post  on the issue are also divided with Ed Snack saying it is important to judge the issue on science not emotion and he points to this link as a starting point. However Macdoctor  evaluates clinical trials and concludes Pharmac’s decision was a budget one.

But then NZ Conservative and several comments at No Minister  back Pharmac.

I am not qualified to argue about the science so I’ll move to the politics and this from TVNZ:

Diane Edwards from Herceptin Heroines says “there’s not a woman in this country that can afford to vote for this government after today’s decision”.

However over at the Hand Mirror Stargazer points out:

… national are saying they will fund the full 12 month course but legally would not be allowed to do so. unless, of course, they change the law to allow political interference in medical decisions.

She is right, Pharmac is independent and there are good reasons why neither the the Minsiter of Health nor the government can intervene. But that will be lost on most people because emotion beats facts in politics. Pharmac is regarded as an arm of government so unpopular decisions from the former will rebound on the latter.

Furthermore, Keeping Stock  points out the only other OECD countries not to fund 12 month courses of the drug are Turkey and Mexico.

As any parent will tell you “nearly everyone else does it” is not a convincing argument. But if most other OECD countries fund the treatment because they can afford to, even if the science is not settled; and we don’t because we can’t afford to then regardless of Pharmac’s independence we are justified in holding the government to account.

5 Responses to Herceptin, health & politics

  1. poneke says:

    if most other OECD countries fund the treatment because they can afford to, even if the science is not settled; and we don’t because we can’t afford to then regardless of Pharmac’s independence we are justified in holding the government to account.

    Pharmac are adamant (in lengthy interviews last night on Checkpoint) that budgetary reasons were not behind this decision, only the science. They would not fund 12 months even if explicitly given money to do so (which they have, anyway) because there is no evidence that administering this hyped-up drug for 12 months has any better outcome than administering it for nine weeks.

    Herceptin is no wonder drug, it appears to have no effect or a negative effect in about 87pc of cases, and very small effects in the rest.

    Its use is being promoted by the drug company. If you look at the media in other countries, you will see that in every case, a young (30ish) attractive woman was trotted out to demand the government fund Herceptin to save her life. It was a huge PR campaign that had a major effect in countries where politics not science decided what new drug was funded.

  2. macdoctor01 says:

    Poneke: I agree with you that Genentech (the company that manufactures Herceptin) is as manipulative as any other drug company. It is also perfectly possible that they originally encouraged the one year course in order to sell more Herceptin. This may be why most of the research is on the one year course.

    And this is the point. Currently there is just not enough research into the nine week course of Herceptin. There are no large-scale trials on this as far as I am aware. Although the small-scale trials indicate that Pharmac may be right, there is just not enough certainty in it to justify the risk to women’s lives. As I have said elsewhere, Pharmac should fund the one year course and review this when convincing information is available about the nine week version. Doing it the other way round is simply playing with women’s lives.

    BTW, Herceptin is only effective in HER-2 types of breast cancer (about 15% of all breast cancers, hence your 87% ineffective statistic). Typically these women are young (but not necessarily attractive!) and the cancer is particularly aggressive and difficult to treat. Even small gains in this group are worthwhile.

  3. exexpat says:

    Mac doctor that’s a bit of catch 22 isn’t it? If the bulk of the large-scale trails are being funded by the drug companies, then they could be used for lobbying fodder or being promoted magic bullet for desperate cancer paitents to sell their major assets for something that might be completly ineffective in the vacuum of information.

  4. Ed Snack says:

    Thanks for the acknowledgement HP, this is a difficult area, and apologies too to Macdoctor if I was too abrupt earlier. It does seem to me that the studies are not yet clear except that the simultaneous use of Herceptin is superior to the “standard” subsequent use.

    Whether we like it or not, there has to be some sort of cost-benefit analysis applied to treatments, and as much as it is seriously possible that is some minor additional benefit from 52 weeks as opposed to 9 weeks, is the extra cost justified overall. Nobody wants to stand up and say who can and who can’t have various treatments, but that is a reality everywhere in medicine. Breast cancer organizations and treatment advocates just happen to be politically more attuned. We simply cannot fund every need, for example why not fund a greater range of Statins rather than Herceptin, arguably it would save a lot more lives, but it doesn’t push the hot buttons. Or why not put a lot more into Melanoma, there are some very promising (and very expensive) treatments turning up for that.

    MacD, something I haven’t spent the time checking, are these studies on selected HER-2 cancer patients only, or on both HER-2 and non-HER-2 patients. If both, has the HER-2 only reduction in mortality been presented ? I thought (and I may be wrong) that it was HER-2 selected, and hence the effect is small, albeit apparently quite real.

  5. fruity says:

    Is that the same Jo Fitzpatrick as from the labour party womens council? If it is, its hardly unusual that she would be the only representative of a womens health group to support the decision, unlike the chorus of disapproval from every other interested advocacy party. Rightly or wrongly, herceptin is/has become a political issue and one could argue her comments are an attempt to take political heat out of the herceptin decision.

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