Friday, 8 August 2008

Red and Blue Pills - Thoughts on the Herceptin debate

This is your last chance. After this, there is no turning back. You take the blue pill - the story ends, you wake up in your bed and believe whatever you want to believe. You take the red pill - you stay in Wonderland and I show you how deep the rabbit-hole goes.
Back when I was a student, I took a course on Health and Public Policy. The lecturer showed us the clip from the Matrix where Neo takes the red pill and wakes up to find that he's been used as a human battery his whole life. The purpose of the clip was to show that policymaking in the health sector is plagued by multiple realities.

I was reminded about this lesson as I've watched the herceptin debate being played out. In the blue corner we have pharmac and some women's health groups arguing that a nine week course of the drug is adequate. While in the red we have a what seems to be a well-respected, well-funded and well-connected campaign for pharmac to reverse its decision and fund a full 12 month course of treatment of the drug.

This debate is just one part of a fairly large 'charity' industry that has sprung up in the health sector pushing ribbons, beads, flowers, badges or whatever other gimmick has been dreamed up to help us open our wallet to the PR people, the merchandisers oh and that health cause we are told we should be giving money to. And thanks to this industry of 'giving' and the insipid celebs all too keen to play the game in order to increase their exposure, we have created a rather dangerous climate where health resources and more importantly research funding are being dictated by popularity and envy rather than actual need.

For instance the launch of Movember which aims to raise awareness of prostate cancer and men's health, both IMHO highly worthy discussions that men should be having, was in part due to the to attention of women's health problems over the last few decades (notice I had to make a disclaimer). My suspicions that this industry is doing our health sphere a disservice were immediately confirmed when the rather vile and cynical copy-cat promotion, fanuary, was launched.

I was venting about this subject to a junior doctor over some bevvies a few months ago. And he agreed that those in need of greatest support and undoubtedly more research suffer from a condition we don't really hear about. They aren't afflicted by breast cancer nor prostate cancer or in fact any cancer at all. Because at the risk of sounding callous, there are really two alternatives to cancer, you either go into remission or you die. Which for the health system is actually quite a tidy outcome either way because the patients don't require on-going support.*

But tidy outcomes for the health system aren't necessarily good for society at large. My great-grandmother died young from breast cancer which caused my great-grandfather to walk out on his family because he couldn't cope with raising two young children alone in depression-era Scotland. Thus my grandmother was raised by an aunt, things went from bad to worse. Due to a lack of money, my grandmother was told at the age of 13 she had to quit school and find a job. Her lack of education is something she tried to remedy later in life, but certainly something that limited her choices in the early part of it.

I can understand why Pharmac might be a bit iffy about funding the 12 month treatment that they think will cost $20-$25 million a year in comparison to the nine-week treatment which is estimated to cost about $6 million a year and the $35-$40 million is spends annually on all cancer drugs. Clearly this is a very expensive treatment, and the 12 month option would clearly benefit Herceptin's maker, Roche quite considerably. However if you consider that a fair portion of those who would receive the treatment are likely to be in the same position as my great-grandmother, young mothers with small kids, the costs to society from the implosion that happened in my family all those years ago are substantial.

But I can't help but wonder how much money and resources Roche has contributed either directly or indirectly to this debate in New Zealand. Who is funding the studies that show the benefits of Herceptin and what impact did Roche's lobbying have in the other jurisdictions that recommend the 12 month treatment? If Pharmac has done its job properly, then those questions have been answered accurately and the New Zealand taxpayer has been saved from funding an unnecessary and expensive treatment. However if they haven't, then treatment of breast cancer in New Zealand has been determined by a lack of funding which I find appalling.

But more than anything I am saddened that this debate has detracted energy and attention from the breast cancer campaigns which might save more lives than this pill, those around early detection. It is generally accepted that the treatment for cancer is most effective when it hasn't had a chance to grow and spread. Thus more awareness amongst women about the importance of self-examination and more importantly better access and take up of breast cancer screening programmes should be capturing our attention far more so that the treatments that we spend our precious health resources on can be their most effective.

*According to the young doctor the major cause of long-term disability in the 18-65 age group comes from Multiple sclerosis. I vaguely remember that the MS society seemed to be a lot more active and even remember selling the four leaf clovers one year as a school student.


Christina said...

The reality is that all health/treatment decisions are, to some extent, determined by funding. This is just as true in countries without public health care systems, although the mechanisms and effects are different (i.e. your health insurer decides what treatments it will fund, and your access to health insurance is determined by your income).

Doctors, DHBs, MoH and Pharmac all have to make decisions every day about how to make the best use of the funding that is available - and those decisions aren't easy ones. The relative benefit of a treatment to the individual and society must be balanced against its cost an availability. And that's not easy to do either, given the prevalence of drug company funded trials - which meta-analyses have shown to be generally biased in favour of the sponsor's product.

And speaking of meta-analyses, a recent one by the Cochrane Centre has found that there is no evidence for breast self-examination being beneficial in screening for breast cancer

But as I understand it, population screening by mammography, is useful for early detection of breat cander in OLDER women (over 50). Not that I am an expert. Which is why I'm glad that we do have experts (including the ones at Pharmac) who I hope try to consider the best evidence (which changes all the time) and make decisions on that basis - not on the basis of well funded pressure groups or popularity!

Anna McM said...

I'm relieved you've written about this Expat - I was wondering if I was the only person conflicted about it, and if I was being a heretic. My scientific knowledge is nil, so I'm not able to weigh up the medical reasoning used by the blue and red corners respectively.

Rationing of healthcare is an issue that even utopian lefties can't avoid considering, since demands for better health and greater longevity will always grow. But even if we accept the need for rationing, we still have to do it in such a way that no particular group is systematically disadvantaged.

A longer course of Herceptin may well be a good thing, but the influence of drug companies, marketers etc means we can't uncritically throw ourselves on any bandwagon, even when the cause (ie women's health) is a good one.

Russell Brown said...

A longer course of Herceptin may well be a good thing, but the influence of drug companies, marketers etc means we can't uncritically throw ourselves on any bandwagon, even when the cause (ie women's health) is a good one.

So true. The manipulation of sentiment by the big drug companies is constant, and makes it difficult to consider the issues clearly. I wrote this in 2006, when a flat-out astroturf project by Roche was pretty well ignored by the local news media: