The method employed by the National Institute for Health and Clinical Excellence to assess the value of cancer drugs could do with some tweaking, a report by the Office of Health Economics suggests.
Since its birth 10 years ago, NICE has based its evaluation of whether a drug is a cost-effective use of National Health Service resources on the cost per QALY (quality-adjusted life year), which takes into account the quantity and quality of life generated by a particular medical intervention.
But the OHE’s the report argues that current methodology may not accurately reflect the value of cancer treatments to patients, and it makes several recommendations to help the cost watchdog better determine the importance of increasing survival and improving the quality of life in those with very short life expectancies.
For example, EQ-5D – a five dimensional questionnaire used to describe health states and their valuations based on the general public’s preferences, and a component of calculating the QALY – may not be “sensitive” enough to recognise fluctuations in the health status of cancer patients, the report says, because it fails to address changes in patients’ vitality or energy.
Alternative assessment?
It is currently being considered whether EQ-5D should be updated to take such fluctuations into account but, in the meantime, the OHE suggests that NICE look at using an alternative – the six-dimensional SF-6D – in the assessment of cancer therapies as it could be more sensitive to such changes.
In addition, health states generated by the EQ-5D questionnaire are based on the general public’s opinion, and the report highlights the potentially significant differences in the values of patients and the public being asked to make choices based on hypothetical situations they may not fully understand.
Furthermore, the preferences of cancer patients are likely to differ depending on the characteristics of their disease, it says. For example, to a patient with six months to live extending survival by two months might be worth more than if they had five years to live, but the QALY valuation does not currently reflect this, the report stresses.
Consequently, one recommendation the OHE makes is that more research be undertaken to determine whether the value of survival gains grows as life expectancy decreases, as well as to define the point at which patients place more value on extending survival than their quality of life. “This would provide a weighting system that better reflects individual utility of health states”, Tina Batchelor from PR group Reynolds-MacKenzie explained to PharmaTimes UK News.
Improving access
The OHE’s report was commissioned by the Pharmaceutical Oncology Initiative – a group of eighteen pharmaceutical firms which joined forces in 2005 to facilitate access to cancer medicines in the UK – in order to assess whether changing NICE’s methodology might help the country attain the same access and survival rates as many of its European peers.
“The POI believes that every cancer patient in the UK should have a chance of survival comparable to the best in Europe,” said Andrew Curl, Chair of POI, but “NICE has declined to recommend some cancer drugs for use in the NHS which are routinely available elsewhere”.
Indeed, according to the government’s Cancer Reform Strategy, launched in December 2007, the UK is lagging way behind other major countries in Europe in terms of access to new cancer drugs, with usage around 40% under that of some of its counterparts.
NICE has already moved to try and improve the picture for patients with rare terminal illnesses, including certain cancers, by raising the current £30,000 cost-effectiveness threshold for certain life-extending therapies.
According to the OHE, the Institute’s new guidelines “make changes that are in line with the main findings of our study,” but it adds that “the lack of detailed rationale for the changes and for the way clinical and cost effectiveness evidence will be appraised by NICE (eg mechanisms to ensure transparency) may make it difficult to apply the changes in practice”.
Whilst welcoming the new guidelines, Professor Adrian Towse, Director at the OHE and co-author of the report, concluded: “We believe that the methodology used for calculating and interpreting QALYs for cancer medicines could be further developed to better value the impact that these new medicines can have on patients and the NHS.”
And if the recommendations made by the OHE are implemented, Curl believes that the benefits to cancer patients in the UK “now and in the future would be immense”.
