Cancer drugs, survival, and ethicsBMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5792 (Published 09 November 2016) Cite this as: BMJ 2016;355:i5792
- Peter H Wise, former consultant physician and senior lecturer
- Charing Cross Hospital and Imperial College School of Medicine, London, UK
- Accepted 24 October 2016
Cancer survival has improved in recent decades. Trends in the US show that five year relative survival in adults with solid cancer has increased from 49% to 68% over 40 years.1 There have been important advances in chemotherapy in recent years, including for melanoma, medullary thyroid cancer, and prostate cancer. Immunotherapy, together with targeted and precision (personalised) approaches guided by patient and tumour biomarkers, also produces benefit in subgroups of the more common cancers.2 But how much of the improvement in cancer survival can we attribute to drugs?
A meta-analysis published in 2004 explored the contribution of cytotoxic chemotherapy to five year survival in 250 000 adults with solid cancers from Australian and US randomised trials.3 An important effect was shown on five year survival only in testicular cancer (40%), Hodgkin’s disease (37%), cancer of the cervix (12%), lymphoma (10.5%), and ovarian cancer (8.8%). Together, these represented less than 10% of all cases. In the remaining 90% of patients—including those with the commonest tumours of the lung, prostate, colorectum, and breast—drug therapy increased five year survival by less than 2.5%—an overall survival benefit of around three months.3 Similarly, 14 consecutive new drug regimens for adult solid cancers approved by the European Medicines Agency provided a median 1.2 months overall survival benefit against comparator regimens.4 Newer drugs did no better: 48 new regimens approved by the US Food and Drug Administration between 2002 and 2014 conferred a median 2.1 month overall survival benefit.5 Drug treatment can therefore only partly explain the 20% improvement in five year survival mentioned above. Developments in early diagnosis and treatment may …