The UK’s drug cost-effectiveness watchdog’s preliminary decision to reject four kidney cancer treatments for use on the National Health Service has unsurprisingly caused outrage among charities and patients.

A draft guidance issued by the National Institute for Health and Clinical Excellence says that Roche's Avastin (bevacizumab), Bayer's Nexavar (sorafenib), Pfizer's Sutent (sunitinib) and Wyeth's Torisel (temsirolimus) are not cost-effective for the treatment of advanced and/or metastatic renal cell carcinoma.

Peter Littlejohns, clinical and public health director at NICE, said that “although these treatments are clinically effective, regrettably, the cost to the NHS is such that they are not a cost-effective use of resources”. He added that two of the manufacturers involved have developed proposals which may have the effect of reducing the cost of the drugs and “we will be happy to consider these proposals”.

Prof Littlejohns said the four drugs have the potential to extend progression-free survival by five–six months, but at a cost of £20,000-£35,000 per patient per year. He noted that the cost per quality adjusted life year (QALY) gained of these treatments is between £28,500-£90,600 per patient (reported by the manufacturers) and £71,500- £171,300 per patient, according to NICE’s independent academic group.

If the four drugs were provided on the NHS, “other patients would lose out on treatments that are both clinically and cost effective”, Prof Littlejohn said. He gave the example of Roche’s Herceptin (trastuzumab), used to treat women with early breast cancer, which costs £20,000 per patient but can extend progression-free life for a number of years. “This makes its cost per QALY gained of around £18,000 per patient.”

The draft guidance is available for public consultation until August 29 and the critics are already making their voices heard. Peter Johnson, chief clinician at Cancer Research UK, said the charity is disappointed, claiming that the decision “once again raises questions about whether NICE's system of appraisal is appropriate for all types of drugs”. He went on to say that “it is often difficult to get unequivocal research data in rarer cancers, such as metastatic kidney cancer, which have a small patient population”.

Prof Johnson added that “although we understand that NICE often has to make difficult decisions, in this case there is a clear separation between what NICE finds to be valuable treatment, and clinical and patient opinion. Action is needed to bring these two positions closer together." Harpal Kumar, the charity’s chief executive, said that possible solutions include looking at the way that pharmaceutical companies are charging the NHS for drugs, “and whether appropriate allowances are being made by NICE to compensate for the lack of large scale trials in these areas”.