What price cure? Because the UK’s National Health Service (NHS) needs to make savings of £20 billion by 2013–14, The Lancet Oncology Commission on the aﬀordability of cancer care1 is highly relevant. To make the appropriate decisions, clear priorities need to be set. However, these priorities are not explicitly identiﬁed by this Commission. The most obvious criterion is whether or not treatment is curative in intent. If the UK is to increase the number of patients diagnosed with cancer who survive by 5000 per year by 2014–15, then surely priority must be given to curative therapies that maximise cancer control and minimise toxicity. This standpoint is particularly important for radiation therapy in view of its eﬀectiveness when combined with chemotherapy for many head and neck and gynaecological malignancies.2,3 Many patients with solid tumours treated by curative radiotherapy are cured. However, the results from a recent survey of UK radiotherapy centres4 were worrying because they showed very limited dissemination of intensity-modulated radiotherapy (IMRT), an advanced radiotherapy technique that allows the adjustment of ﬂuence of the x-ray beam to the tumour contours, minimising dose to normal tissues. This limited dissemination is despite evidence that IMRT maintains parotid saliva production and reduces acute and late xerostomia in advanced head and neck cancer and late rectal toxicity in prostate cancer.5 A shortage of specialist staﬀ and scarcity of funding have been identiﬁed as barriers to dissemination. These ﬁndings resonate with those of the Commission, which reported that although 60% of patients in the USA receive radiation during their course of treatment, “there is mounting concern that undiscerning analysis of medical evidence could lead to asymmetric allocation of resources away from this discipline”.1 The reasons for this asymmetry are unclear, but could be because some www.thelancet.com/oncology Vol 13 January 2012
believe that where radiotherapy access is constrained, adequate medical and surgical alternatives do exist, or that radiotherapy is an old technology that will be imminently replaced by breakthroughs in systemic therapy. It is surprising too that the Commission does not cite the abundant evidence6 on the cost-eﬀectiveness of curative or palliative radiotherapy. A £200 million fund has been established by the UK government to widen patients’ access to anticancer agents (often with palliative intent) for which no local NHS funding is available. No equivalent fund has been established to support access to stereotactic radiotherapy for the curative treatment of medically inoperable early-stage non-smallcell lung cancer, for example, despite evidence of its cost-eﬀectiveness.7 The national variations in access to advanced radiation technologies are likely to become more widespread as clinicians follow General Medical Council guidance and inform patients of other centres where better treatment is available. If evidencebased decisions on expenditure on cancer care are to be made with limited resources, a level playing ﬁeld is needed among the diﬀerent treatment modalities so that patient outcomes are optimised. I declare that I have no conﬂicts of interest.
Ian Kunkler [email protected]
Edinburgh Cancer Centre, School of Molecular and Clinical Medicine, Department of Clinical Oncology, University of Edinburgh, Western General Hospital, Edinburgh, UK 1
Sullivan R, Peppecorn J, Sikora K, et al. Delivering aﬀordable cancer care in high-income countries. Lancet Oncol 2011; 12: 933–80. Pignon JP, le Maitre A, Maillard E, et al. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): an update on 93 randomised trials and 17,346 patients. Radiother Oncol 2009; 92: 4–14. Green JA, Kirwan JM, Tierney JF, et al. Survival and recurrence after concomitant chemotherapy and radiotherapy for cancer of the uterine cervix: a systematic review and meta-analysis. Lancet 2001; 358: 781–86. Mayles WP. Survey of the availability and use of advanced radiotherapy technology in the UK. Clin Oncol 2010; 22: 636–42.
Staﬀurth J. A review of the evidence for intensity-modulated radiotherapy. Clin Oncol 2010; 22: 643–57. Barton MB, Gebski V, Manderson C, et al. Radiation therapy: are we getting value for money? Clin Oncol 1995; 7: 287–92. Sher DJ, Wee JO, Punglia RS. Cost-eﬀectiveness analysis of stereotactic body radiotherapy and radiofrequency ablation for medically inoperable, early-stage non-small cell lung cancer. Int J Rad Oncol Biol Phys 2011; 81: e767–74.
Aﬀordable cancer care We congratulate the authors of The Lancet Oncology Commission for their comprehensive report on aﬀordable cancer care.1 We are in dire need of new and eﬀective anticancer drugs and technologies at fair prices, but the solution is not simple, nor easy. However, instead of a focus on aﬀordability, the problems facing development of drugs with clinically meaningful and sustained beneﬁts should probably have been addressed ﬁrst. Accordingly, our comments are not directed at the soundness of advice in the Commission, but at the analysis of the problem, and to the sequence of steps put forward to correct it. Market size is a more powerful determinant of revenues and proﬁts than high prices, so the pharmaceutical industry would stand to gain far more from a high volume of sales of better medicines at much lower prices. We believe the aﬀordability problem lies in outmoded regulations that are blocking the development of targeted anticancer agents. At present, there is no clear regulatory route for the demonstration of a clinical eﬀect of a drug on tumour metastasis.2 The Commission did not analyse the cause of this market and regulatory failure. As with all products, an increase in demand leads to high prices, and a high proﬁt attracts competition, which eventually lowers prices to aﬀordable levels. This has not happened with anticancer therapies because of the high degree of attrition in development, possibly due to mediocre science or unsuitable clinical evaluation. Much attention has been directed to the e2