Charlotte A Chamberlain

A systematic review of geographical variation in access to chemotherapy.

BackgroundRising cancer incidence, the cost of cancer pharmaceuticals and the introduction of the Cancer Drugs Fund in England, but not other United Kingdom(UK) countries means evidence of ‘postcode prescribing’ in cancer is important. There have been no systematic reviews considering access to cancer drugs by geographical characteristics in the UK.MethodsStudies describing receipt of cancer drugs, according to healthcare boundaries (e.g. cancer network [UK]) were identified through a systematic search of electronic databases and grey literature. Due to study heterogeneity a meta-analysis was not possible and a narrative synthesis was performed.Results8,780 unique studies were identified and twenty-six included following a systematic search last updated in 2015. The majority of papers demonstrated substantial variability in the likelihood of receiving chemotherapy between hospitals, health authorities, cancer networks and UK countries (England and Wales). After case-mix adjustment, there was up to a 4–5 fold difference in chemotherapy utilisation between the highest and lowest prescribing cancer networks. There was no strong evidence that rurality or distance travelled were associated with the likelihood of receiving chemotherapy and conflicting evidence for an effect of travel time.ConclusionsConsiderable variation in chemotherapy prescribing between healthcare boundaries has been identified. The absence of associations with natural geographical characteristics (e.g. rurality) and receipt of chemotherapy suggests that local treatment habits, capacity and policy are more influential.

The association of weight gain during adulthood with prostate cancer incidence and survival: a population-based cohort.

Obese men appear to have an increased risk of being diagnosed with advanced prostate cancer and of dying from the disease. Few studies have examined the impact of weight gain during adulthood on prostate cancer risk and mortality and these have reported conflicting results. We analysed data from 20,991 Norwegian men who participated in two phases of the Nord‐Trøndelag Health Study in 1984/1986 (HUNT‐1, when aged at least 20 years) and 1995/1997 (HUNT‐2). Weight and height were measured at both HUNT‐1 and HUNT‐2, allowing each mans change in weight and body mass index (BMI) to be computed. During a median of 9.3 years of follow‐up after the end of HUNT‐2, 649 (3%) men developed prostate cancer. We observed no increase in prostate cancer incidence amongst men who put on weight between HUNT‐1 and HUNT‐2. In multivariable models, including adjustment for weight at HUNT‐2, the hazard ratio (HR) for prostate cancer per one standard deviation, SD (6.2 kg) gain in weight was 0.98 (95% confidence interval [95% CI] = 0.87–1.10, p‐trend = 0.70) and per one SD gain in BMI (1.9 kg/m2) was 0.99 (95% CI = 0.90–1.10, p‐trend = 0.88). Amongst men diagnosed with prostate cancer (any stage), there was no evidence that gain in weight before diagnosis was positively associated with subsequent all‐cause mortality (HR per one SD increase in weight = 0.98; 95% CI = 0.81–1.19, p‐trend = 0.86). We conclude that weight gain in adulthood had no effect on prostate cancer incidence or survival in this population.

Do patient access schemes for high-cost cancer drugs deliver value to society?-lessons from the NHS Cancer Drugs Fund.

Abstract Background The NHS Cancer Drugs Fund (CDF) was established in 2010 to reduce delays and improve access to cancer drugs, including those that had been previously appraised but not approved by NICE (National Institute for Health and Care Excellence). After 1.3 billion GBP expenditure, a UK parliamentary review in 2016 rationalized the CDF back into NICE. Methods This paper analyses the potential value delivered by the CDF according to six value criteria. This includes validated clinical benefits scales, cost-effectiveness criteria as defined by NICE and an assessment of real-world data. The analysis focuses on 29 cancer drugs approved for 47 indications that could be prescribed through the CDF in January 2015. Results Of the 47 CDF approved indications, only 18 (38%) reported a statistically significant OS benefit, with an overall median survival of 3.1 months (1.4–15.7 months). When assessed according to clinical benefit scales, only 23 (48%) and 9 (18%) of the 47 drug indications met ASCO and ESMO criteria, respectively. NICE had previously rejected 26 (55%) of the CDF approved indications because they did not meet cost-effectiveness thresholds. Four drugs—bevacizumab, cetuximab, everolimus and lapatinib—represented the bulk of CDF applications and were approved for a total of 18 separate indications. Thirteen of these indications were subsequently delisted by the CDF in January 2015 due to insufficient evidence for clinical benefit—data which were unchanged since their initial approval. Conclusions We conclude the CDF has not delivered meaningful value to patients or society. There is no empirical evidence to support a ‘drug only’ ring fenced cancer fund relative to concomitant investments in other cancer domains such as surgery and radiotherapy, or other noncancer medicines. Reimbursement decisions for all drugs and interventions within cancer care should be made through appropriate health technology appraisal processes.

Does the cancer drugs fund lead to faster uptake of cost-effective drugs? A time-trend analysis comparing England and Wales

Background:The Cancer Drugs Fund (CDF) provides £200 million annually in England for ‘anti-cancer’ drugs.Methods:We used a controlled pre-/post-intervention design to compare IMS Health dispensing data for 15 cancer drugs (2007–2012) in England vs Wales, stratified by pre-CDF NICE drug approval status (rejected, mixed recommendations, recommended, not appraised).Results:The CDF was associated with increased prescribing in England for three of five drugs rejected or with mixed NICE recommendations. The prescribing volume ratios (PVR) ranged from 1.29 (95% CI 1.00, 1.67) for sorafenib to 3.28 (2.59, 4.14) for bevacizumab (NICE rejected) and 0.93 (0.81, 1.06) and 1.35 (1.21, 1.49) for sunitinib and imatinib respectively (mixed recommendations). Post CDF prescribing in England increased for both drugs awaiting NICE appraisal pre-CDF (lapatinib PVR=7.44 (5.81, 9.54), panitumumab PVR=5.40 (1.20, 24.42)) and subsequently rejected. The CDF was not associated with increased prescribing in England of NICE-recommended drugs. The three most recently launched, subsequently recommended drugs were adopted faster in Wales (from pazopanib PVR=0.51 (0.28, 0.96) to abiraterone PVR=0.78 (0.61–0.99)).Interpretation:These data indicate that the CDF is used to access drugs deemed not cost-effective by NICE. The CDF did not expedite access to new cost-effective cancer agents prior to NICE approval.

NICE recommendations for disinvestment

Garner and Littlejohns summarise the difficulties faced by the National Institute for Health and Clinical Excellence (NICE) in identifying low value NHS activities.1 NICE’s work has evolved from new appraisals of specific technologies towards initiatives that include hundreds of do not do recommendations drawn predominantly from existing clinical guidelines.2 Evidence that these initiatives are effective is mixed and limited.3 NICE should reconsider its shift away …

Where is the evidence for the existence of the Cancer Drugs Fund

Professor Peter Clark congratulates the Cancer Drugs Fund (CDF) for reimbursing drugs only at the lowest price proposed for use in the NHS, but he is later quoted conceding that “some [pharmaceutical] companies have seen the CDF as an easy route to funding . . . because they don’t have to drop the price to get CDF …

UK newspaper reporting of the NHS cancer drugs fund, 2010 to 2015: a retrospective media analysis

Objective We wished to explore how UK national newspapers had covered the creation and operation of the Cancer Drugs Fund from 2010 to 2015. This was introduced to provide cancer patients in England with access to drugs not appraised or approved by the National Institute for health and Care Excellence. Design We sought stories in nine newspapers from the Factiva database, and copied their salient details to a spreadsheet. They were categorised by whether they were supportive or critical of the Cancer Drugs Fund and their main arguments, which drugs they mentioned and for which cancers. Settings Not applicable Participants Not applicable Main outcome results Press coverage was mainly very positive, arguing for the Cancer Drugs Funds extension to Scotland and Wales, and a bigger budget, but neglecting the lack of patient benefit and the severe side effects that sometimes occurred. Leading this support was the Daily Mail, whose influence (measured by the product of number of stories and the papers circulation) was almost greater than that of the other newspapers combined. Results Press coverage was mainly very positive, arguing for the Cancer Drugs Fund’s extension to Scotland and Wales, and a bigger budget, but neglecting the lack of patient benefits and the severe side effects that sometimes occurred. Leading this support was the Daily Mail, whose influence (measured by the product of number of stories and the paper’s circulation) was almost greater than that of the other newspapers combined. Conclusions Although there was some critical analysis of the Cancer Drugs Fund, our analysis shows that most press coverage was largely positive and unrepresentative in comparison with the lack of overall benefits to patients and society. It is likely that it contributed to the Cancer Drugs Fund’s continuation despite mounting evidence of its ineffectiveness.

A mixed methods study on the prioritisation of cancer and access to cancer drugs: the Cancer Drugs Fund in England

Abstract Background By April, 2016, the Cancer Drugs Fund (CDF) will have provided £1·27 billion. The CDF funds high-cost cancer drugs that have not been recommended or appraised by the National Institute for Health and Care Excellence. We aimed to combine the viewpoints of patients and clinicians about fair access to cancer drugs with measured equity of access to cancer drugs in the National Health Service. Methods We conducted semi-structured interviews with consultants in oncology and palliative care (n=16) and patients with terminal prostate and colorectal cancer (22) recruited from hospitals in South West England to explore values underpinning decisions about prioritisation. Researchers were independent of the clinical team and CDF. Qualitative thematic analysis was done with principles of constant comparison and facilitated by NVivo (version 10). Equity and timeliness of access to cancer drugs was assessed in cross-sectional (n=3193) and cohort (899) studies of South West CDF (2011–13) patients, respectively. We assessed equity by comparing access to the CDF in a reference eligible population of advanced type-matched patients from the South West Cancer Registry by age, sex, deprivation, and cancer network using χ 2 tests. Performance status was absent and not controlled for. Timeliness of treatment was assessed with Cox regression to calculate time from CDF authorisation to start of treatment by the same characteristics. Findings All but one interviewed clinician agreed that having a ring-fenced fund for cancer drugs was not the best use of National Health Service resource. Almost all patients and professionals felt that prioritising cancer over other diseases was unjustified. Prioritising life extension at the end of life raised concerns for many professionals, but for fewer patients. Older people (≥80 years) and women were less likely to have been referred to the CDF: in colorectal cancer, 45 (6·9%) of 648 older patients accessed the CDF (30·1% eligible [483/1606]; difference 23·2%, 95% CI 20·2–26·2). In malignant melanoma, 46 (36·8%) of 125 women accessed the CDF (48·7% eligible [1680/3453]; difference 11·9%, 3·1–20·7). There was regional variation in prescribing by cancer network, which was inconsistent across cancer types. Differences in treatment timeliness were negligible. Interpretation The CDF lacks legitimacy for this population of users, and is unequal in its delivery. We recommend that a fundamental re-evaluation of the CDF is undertaken to ensure appropriate resource allocation according to population values. Funding CC is a National Institute for Health Research Doctoral Fellow.

Professional experiences of accessing cancer drugs in the NHS: the introduction of the Cancer Drugs Fund, the individual versus the population

Background The establishment of the Cancer Drugs Fund (CDF), which removed the necessity for cost-effectiveness as a criterion for drugs access and expedited access to nonNICE appraised drugs, has significantly changed prescribing of cancer drugs for terminally ill cancer patients in the NHS. Neither clinicians nor the public have a preference for spending money on cancer over other disease states. The most effective and efficient way to spend resource within cancer care is hotly debated.

The association of weight gain during adulthood with prostate cancer incidence and survival: the HUNT-2 cohort, Norway: a population-based cohort

Obese men appear to have an increased risk of being diagnosed with advanced prostate cancer and of dying from the disease. Few studies have examined the impact of weight gain during adulthood on prostate cancer risk and mortality and these have reported conflicting results. We analysed data from 20,991 Norwegian men who participated in two phases of the Nord‐Trøndelag Health Study in 1984/1986 (HUNT‐1, when aged at least 20 years) and 1995/1997 (HUNT‐2). Weight and height were measured at both HUNT‐1 and HUNT‐2, allowing each mans change in weight and body mass index (BMI) to be computed. During a median of 9.3 years of follow‐up after the end of HUNT‐2, 649 (3%) men developed prostate cancer. We observed no increase in prostate cancer incidence amongst men who put on weight between HUNT‐1 and HUNT‐2. In multivariable models, including adjustment for weight at HUNT‐2, the hazard ratio (HR) for prostate cancer per one standard deviation, SD (6.2 kg) gain in weight was 0.98 (95% confidence interval [95% CI] = 0.87–1.10, p‐trend = 0.70) and per one SD gain in BMI (1.9 kg/m2) was 0.99 (95% CI = 0.90–1.10, p‐trend = 0.88). Amongst men diagnosed with prostate cancer (any stage), there was no evidence that gain in weight before diagnosis was positively associated with subsequent all‐cause mortality (HR per one SD increase in weight = 0.98; 95% CI = 0.81–1.19, p‐trend = 0.86). We conclude that weight gain in adulthood had no effect on prostate cancer incidence or survival in this population.