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In the United Kingdom the "value for money" of new medical technologies is formally assessed through the National Institute for Health and Clinical Excellence (NICE), which commissions cost effectiveness analyses. These analyses are summarised in terms of cost per quality adjusted life year. Services with a cost per quality adjusted life year less than £30â[euro][per thousand]000 are usually viewed as good value for money, and NICE will recommend their adoption by the National Health Service. 1 2
The debate over trastuzumab (Herceptin) in early breast cancer has highlighted a major deficiency in the system-although NICE now recommends adopting this new technology, it provides no extra funding and does not suggest what cuts should be made to release these extra funds. 3 We outline how the cost of giving Herceptin should not be measured in money alone, but also in the treatments that will have to be dropped to balance the books.
The Herceptin debate
Herceptin is a monoclonal antibody against the HER2 protein that is overexpressed in 20-25% of patients with breast cancer. For palliation and in certain other clinical circumstances, NICE recommended its use in women whose tumours have high (3+) expression of the HER2 receptor. 4 The NICE appraisal of Herceptin as adjuvant treatment has just been released, and the National Cancer Research Institute has also issued clinical guidelines. 3 5
Readers will be aware of the heated debate surrounding this treatment. 6 7 The media have made little mention of the restricted categories of patients for whom Herceptin may be appropriate, or of the lack of long term toxicity data, especially concerning effects on the heart. Although the three published trials showed a statistically significant improvement in rates of recurrence, as yet, only one has shown a benefit in survival (4.8% at four years). 8 9 10 Despite the lack of NICE approval at the time, several patients obtained Herceptin through their local NHS by appealing to the courts. 11 NICE promised to "fast track" Herceptin, and it is no surprise that the resulting guidance is positive. 12
This means that our trust (Norfolk and Norwich University Hospital) will have to find £1.9m (â,¬2.9m; $3.6m) each year in drug costs alone to make Herceptin available to the 75 patients who may be...