This episode of the BBC current affairs series Panorama follows the story of seven women with breast cancer who campaigned to receive the drug Herceptin. It is a classic example of the tensions arising from the rise in effective but expensive new medicines set against the constrained budget of the National Health Service. At the time of filming (Summer/Autumn 2005), treatment with Herceptin cost £30,000 per patient per year and was exclusively licensed for use against advanced-stage breast cancer. However in light of some promising and well-publicised clinical trials, and motivated by Prime Minister Tony Blair’s pledge that “Cancer patients in all parts of the country will get the right drugs at the right time, regardless of where they live” (00:02:50-00:03:10), seven women with early-stage breast cancer believed that this drug may well help save their lives. The programme follows their campaign as it snowballs from a local issue to achieve national support (00:11:45-00:13:50).
The central ethical question raised by this programme is, therefore, one of resource allocation. There is a cost-benefit analysis to be done for the treatment per se, but this also has to be seen in a broader context; a decision to fund one therapy means a decision elsewhere in the system that likely denies somebody the treatment that they want. How do you evaluate one course of treatment over another? How do you fairly distribute public resources between patients? Can you judge the value of one life against another?
There are a number of quotes within the programme that nicely convey this dilemma. Dot Griffiths, who was diagnosed with advanced stage breast cancer and whom led the campaign, has been on Herceptin for four years. “I know it works” she says, “I’m living proof that it works”, adding that she “can’t express in words how passionately I feel about Herceptin, because it has given me another chance of life” (00:09:09-00:10:30). As the women embark of their campaign to receive the drug on the NHS, the reporter Betson Powys acknowledges that the women recognised “that it was expensive and that giving it to them would mean trade-offs elsewhere in the NHS, but they were not prepared to lose out” (00:11:22-00:11:33).
At an extra cost of £100 million a year to treat every woman in the UK, the question is raised “how much more likely are those women to survive?” (00:13:26-00:13:41). Professor Ian Smith, Lead UK investigator on the Herceptin trial notes that “all the trials have already got less deaths in the patients who had Herceptin then in the patients that didn’t” but goes on to question the significance of these results, admitting that “we don’t know yet” whether Herceptin is the wonder drug being reported (00:13:41-00:14:05). Dr Karol Sikoza, a distinguished Professor in Cancer Medicine, comments on this challenging dilemma; “the data suggests that you have to give it to eighteen women to get one life saved. So the cost is over £400,000 for that one life. If you’re the women whose life is being saved then, of course, it’s a wonder drug for you. The other seventeen don’t know whether it’s going to be or not, but obviously with the drug there they want the best possible treatment. That’s the conundrum, you have to give it to a lot of people to get the 6% benefit overall” (00:24:45-00:25:50).
Such comments illustrate the difficulties of making such decisions; on the one hand you have a group of patients, all with a life-threatening illness, all believing there is a drug available which could increase their chances of survival. On the other there is this limited pool of resources which, according to utilitarian principles, should be used in a way that maximises the benefit to the largest number of people. It has always been the case that “finite resources have never met infinite need” (Betson Powys, 00:18:15), but in light of the campaign, Dr Karol Sikoza believes it is unfair to society if funds are taken “from services that don’t have a powerful lobby – mental handicapped, care of the elderly, public health” and provide them for those that do (00:32:20-00:33:30).
In the UK, steps have been taken to endeavour to steer a course through this minefield. The unenviable task is carried out by NICE, the National Institute of Clinical Excellence (00:17:55-00:19:35), which scrutinises the evidence for a drug’s clinical use and analyses the cost implications to ensure value for money. The section from 00:17:00 to 00:33:50 would be an excellent tool for highlighting the central arguments and discussions surrounding this topic.
Although it is not discussed overtly in this programme, Herceptin is also worthy of note in a different bioethical context, as early example of “personalised medicine” in the emerging field of pharmacogenomics. Herceptin is only effective if the cancerous cells in the patient express a particular cell-surface protein, called HER2 (for an excellent introduction to the molecular biology of this process, see the tutorial on the PHG Foundation website). If a woman’s malignant cells do not have this protein then there is no value to be derived in giving her the drug. This knowledge is of huge benefit in targeting resources appropriately; money is not wasted in giving expensive medication to someone who will derive no benefit, and valuable time in choosing a better remedy is not squandered. In the future, it is anticipated that there will be much more use of genetic information to selected appropriate drug regimes.
Herceptin: Wanting the wonder drug (46 minutes in total) was first broadcast on BBC1 at 22:15, on 5th February 2006. At the time of writing (8th January 2008), this programme is still available on the BBC Panorama ‘Archive’ section of their website, where a link can also be found to a BBC News 24 debate on the topic. Alternatively, BUFVC members can obtain a copy of the programme for educational use (TRILT Identifier: 00573D8A).