Trastuzumab for early breast cancer raises important issues

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7523.1023-a (Published 27 October 2005) Cite this as: BMJ 2005;331:1023
  1. Edward C F Wilson, research associate (ed.wilson{at}uea.ac.uk)
  1. Health Economics Group, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ

    EDITOR—The government's recent announcement that all early stage breast cancer patients are tobe tested for HER2 overexpression with a view to receiving trastuzumab (Herceptin) will no doubt be a great relief to both patients and oncologists1.

    However, this raises several important issues.

    Firstly, the government may be setting a dangerous precedent in effectively promoting off-licence indications for a pharmaceutical (what oncologist, presented with a patient who could benefit from this drug, will not use his or her clinical discretion to prescribe it off-label?).

    Secondly, it is pre-empting the evaluations of both the European Agency for the Evaluation of Medicinal Products (EMEA, the licensing agency) and the National Institute for Health and Clinical Excellence (NICE), the body set up to advise the government on value for money in the NHS.

    But most importantly, it highlights the terrible decisions necessary in any health system: theoncologist sees a sick patient and knows there is a treatment available that may help them. However, the director of public health in the primary care trust has limited funds (which in many cases are already overspent) and a duty to get the best possible health care for the entire population with those funds. Trastuzumab costs in the region of £20 000 per patient per year. A typical primary care trust (170 000 population) may have 23 eligible patients,2 thus costing an additional £460 000. Without the drug, on average two of the patients may die each year.3 With it, one of them may survive.4 Therefore the stark decision faced by the trust is whether it can withdraw £460 000 from other services at a “cost” of less than one life elsewhere. To this there is no easy answer.


    • Competing interests None declared.


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