NICE approves Lucentis but remains in the eye of the storm

Earlier today, the National Institute for Health and Clinical Excellence (NICE) announced its final guidance, approving reimbursement for the use of ranibizumab (Lucentis) and pegaptanib (Macugen) for the treatment of age-related macular degeneration (AMD). This will please many (ie, patients, prescribers, pharma companies and, it seems, the press and the public).

But the decision will also irritate others (ie, the payers), because a course of treatment will cost NHS Trusts up to £10,000 per eye. This is particularly hard to swallow because it will indirectly end the possibility to treat AMD patients with a related drug, Avastin, that is significantly cheaper. Avastin is approved for colorectal cancer, but has been used off-label to treat AMD. The company that developed both Avastin and Lucentis has announced that it has no intention to register AMD as an indication for Avastin, on the basis that Lucentis has been modified in a number of ways that make it more a appropriate treatment. Clearly, delivering more value justifies an increased price, but many observers consider the price increase in this case to be unduly high.

Surely feeding into this decision was the innovative compromise negotiated with Novartis, who markets Lucentis in the UK, for the supplier to meet the cost of any injections required by a patient beyond the 14 specified in the guidance. This is an example of risk-sharing and value-based pricing that I, for one, applaud, and hope to see more frequently.

But despite NICE pleasing many with this announcement, they remain in the centre of a media storm following its recent decisions not to approve a number of drugs for patients with advanced kidney cancer. A few days ago, a number of eminent cancer specialists wrote of their dismay in a letter to The Times. They argued that the UK spends less than two-thirds of the European average on cancer drugs and that the models used by NICE need to be radically changed.

These are two separate points, and agreeing with one doesn’t necessarily extend to the other. The UK is widely regarded as a world leader in the field of health economics, so while I’m sure even NICE would agree that there is room to improve on their modelling, one should not assume that more sophisticated models would bring the UK into line with the rest of the EU; in fact, the models used elsewhere in the EU are likely to become more similar to those of the UK.

The one thing that does differ, though, is public attitude to value, and this is where the question becomes more one of politics than of science or economics. If a society decides to place more value on treating cancer, recognising that this would mean spending less on other conditions, perhaps without such an active patient advocacy group, then the parameters of the health economic model would change and reimbursement decisions might be different.

If a sophisticated analysis is carried out in a timely, efficient way but arrives at an answer we don’t like, the first place to look is the public values used to underpin the analysis. If these are accurate, maybe it isn’t NICE that should be criticised, but society in general.