Sunday, June 03, 2007

Herceptin and the Right to Health Care

Quite a while ago, under a post of mine on health care, Sage NZ, made the following comment.

"But when it comes to health, in my opinion, every New Zealander does have the right to health care" so the question for you is whether or not that includes herceptin?
There's more to his comment but the above bit is the interesting sentence.

Sage is making reference to the part of my own post where I say that:
Markets, when they function properly, optimise efficiency. They promise nothing when it comes to distribution. Or in other words, a purely market system, doesn’t guarantee provision of services or products to all. That’s fine when it comes to Hamburgers – I don’t think every New Zealander has the intrinsic right to eat McDonalds. But when it comes to health, in my opinion, every New Zealander does have the right to health care.
Herceptin has, of course, attracted much media attention in New Zealand recently as the miracle cancer drug that Pharmac (the New Zealand drug funding agency) refused to fund for women with early-stage breast cancer (Herceptin is, IIRC, already funded for women with advanced breast cancer) despite evidence that the drug halved the recurrence rate of the disease. Pharmac found itself caught in a pincer movement between the publicity campaign of the
drug company that produced the drug, the lobbying of breast cancer suffers who - quite understandably - are keen for access to a drug that may save their lives, and some of the worst media reporting imaginable.

Buried among all this clamour were a few important facts. The first of these being that survival rates among women with early-stage breast cancer are already high so, while a 50% reduction sounds impressive, it needs to be borne in mind that, in an absolute sense, the numbers of livessavecd are small. At the same time Herceptin brings with it an increased risk of heart disease. The New Scientist explains [open link]:
Now, appreciating the drug's true benefit means understanding relative and absolute risk. That 52 percent is a reduction in relative risk. Since the chance of breast cancer recurring when treated early is already small, a 52 per cent reduction in that risk is commensurately small. Even women with early breast cancer who receive no treatment after lumpectomy, see recurrence peak at 10 per cent per year after two years, then drop, levelling off at around 3 per cent at 10 years. After other standard therapies, recurrence is lower still. Importantly, as in many trials, prolonging life isn't the main yardstick: researchers focus on how long a drug can keep patients disease-free. However, the disease may return, often with renewed vigour. So disease-free survival does not by any means translate into prolongation of life.

Looking at overall survival rate at the end of one of the studies, there were 37 deaths in the control group (2.2 percent) as opposed to 29 deaths (1.7 per cent) in the Herceptin group. The slight difference in the deaths was most likely chance alone, so adding Herceptin to chemotherapy conferred no meaningful survival advantage.

Now, Herceptin does have a small but significant positive effect on the absolute rate of recurrence in a minority of women with early stage breast cancer. But look closely at the causes of death. In one of the studies, there were 23 breast-cancer related deaths (1.4 per cent) in the Herceptin group compared with 34 (2.0 per cent) in the observation group. In terms of absolute risk, the Herceptin group achieved a very modest 0.6 per cent reduction in breast-cancer related deaths. This small gain has, however, to be weighed against the fact that Herceptin turns out to produce heart damage in 4.1 per cent of the early-stage breast cancer patients.
Oh, and there's one other thing: Herceptin treatment carries with it a price tag of over $60,000 per person.

Once you become aware of this (which you wouldn't do if you relied on our TV 'current affairs' programmes) Pharmac doesn't seem quite so heartless for refusing funding (and, in the end they even compromised on this agreeing to pay for a 9 week treatment course of the drug - something that appears to be as effective as the full 52 week treatment).

And yet, I have to confess that - so long as the decrease in cancer mortality is isn't outweighed by the increase in heart disease mortality - I'd still support the funding of the Herceptin. Even if the absolute number of women's lives saved is small they are still lives saved; people's mothers, sisters, and daughters who will get the chance to live longer and happy lives.

The trouble is though, the drug needs to be paid for. The easy answer would simply be to raise taxes accordingly, but that's hardly going to happen in today's political climate. The other option is taking the money from something else, most likely from Pharmac's budget, which means that other potentially more effective treatments for other diseases may have to be sacrificed.

And this, I think, gets to the heart of Sage's question: if you view health care as a right, regardless of one's level of wealth, as I do, where do you draw the line?

This is a very good question as - in upcoming years - thanks to the ever expanding basket of treatments available (and patented) and thanks to our aging population (the elderly being more medicine intensive) the price of running an all-inclusive public health care system is going to increase substantially.

Sage's own preferred solution - privatisation - is a non starter for the simple reason that the evidence suggests that private health care systems like the United States's are even less efficient than our own. What's more, despite Medicaid, the United States still has a significant proportion of its population without access to health care. It might work if you're wealthy but it sure ain't health care as a right.

My preferred solution, raised taxes, would require more sophistication from our democracy than currently seems possible (having a media that effectively functions as a tax cuts lobby doesn't help).

Which leads to the probable outcome of rationing where, some basic health care will still be provided to the public, but where access to the rest will depend on wealth. This, obviously, is an option that I'd be keen to avoid.

Perhaps we may be able to squeeze more efficiency out of our current system, but I'm not sure. Efficiency seems largely to be a byword for overworked doctors and nurses.

More promising, perhaps, is a shift to preventative care wherever possible. There are considerable benefits associated with moving the ambulance to the top of the cliff. Getting it there though, still isn't an easy task. How, exactly, does the state (dear ol' nanny-state) get people to exercise more and eat more fruit and vegetables?

All thoughts welcome...


sagenz said...

wow - talk about a good return on investment. I write a short para and get a very well written post.

I started on the economist link and dont have time to rebut/comment in detail now. but thanks. I will return

Terence said...

thanks sage - I look forward to your reply.