What price human life? Resources and the Doctor-patient relationship

Jaws WheelsLast Wednesday I saw an unfortunate middle-aged man with severe Acromegaly. As students in UK’s premier Medical School I need not remind you about this condition – but if you having an off day think of “Jaws” in the James Bond movies and this is your prompt; a growth hormone (GH) secreting tumour of the pituitary gland that causes large hands and feet, disabling symptoms (tiredness, sweating, arthralgia, paraesthesia, headaches) and premature cardiovascular mortality. Treatment involves pituitary surgery with radiotherapy and medical therapy for persistent disease. Medical therapies have advanced significantly so that virtually every patient can be cured, albeit with a very expensive and novel drug called pegvisomant that works by blocking the GH receptor [1]. In my practice of over 500 cases I have needed to use this medication on no more than a handful of cases. In doing so I believe I am fulfilling my prime responsibility to the patient in providing optimal therapy. Ok so far, but the new drug costs £35,000/ year; hospitals by and large do not have prescribing budgets and understandably no GP that I have ever approached has been willing to take this on. So does this represent a dilemma in the accepted doctor:patient relationship whereby extraneous financial factors are now affecting your ability to treat the patient? In fact the role of the doctor has changed accordingly in recent to recognise this very conundrum.  “Notwithstanding the primacy of the individual doctor-patient relationship, the doctor must appreciate the needs of the patient in the context of the wider health needs of the population. Within a world where the capacity to treat is growing but financial resources finite, doctors have a duty to use resources wisely” [2].  In assisting the process the National Institute for Health and Clinical Excellence (NICE) advises NHS and Doctors on the cost effectiveness of new medicines. In a somewhat complicated process (at least to a mere physician such as myself), the evidence is based on the cost of the new intervention per quality of adjusted life years (QALY) – a measure that takes into account any change in mortality as well as quality of life [3]. Pegvisomant has yet to be put through this process, but with so few patients across the UK, and therefore so little evidence base it is unlikely to get approval.

Those of you who managed to read more than the latest X-factor gossip in this week’s papers will have noticed a similar process around bevacizumab (Avastin) for patients with advanced bowel cancer [4]. Bevacizumab is an exciting new monoclonal antibody that works by blocking vascular endothelial growth factor A. It is thought that an inhibitory action on angiogenesis is one method by which it improves prognosis in patients with metastatic colorectal cancer. In an area crying out for new therapies this advance was warmly received by patients and doctors alike, but having reviewed the evidence NICE was unable to support its prescription on the NHS in the UK – at £21,000/year it added on average 6 weeks to a patient’s life – far below the QALY threshold required. No doubt that the drug works, but the cost effectiveness in a rationalised healthcare system dictates that resources should be directed to more worthwhile endeavours [5].

So as you progress through Medical School and early clinical training be aware that your priori role in putting the patient first can be tempered by factors outside your control, in this case the level at which UK Society is prepared to support new therapeutic advances. This will need you to manage a slightly different doctor-patient relationship as well as reconcile your own professional values and satisfaction.

[1] Trainer PJ, Drake WM, Katznelson L, et al.  Treatment of acromegaly with the growth hormone-receptor antagonist pegvisomant.  New Engl J Med. 2000; 342(16):1171-7.

[2] http://www.medschools.ac.uk/AboutUs/Projects/Documents/Role%20of%20Doctor%20Consensus%20Statement.pdf

[3] http://www.nice.org.uk/newsroom/features/measuringeffectivenessandcosteffectivenesstheqaly.jsp

[4] http://www.cancerhelp.org.uk/about-cancer/treatment/cancer-drugs/bevacizumab

[5] http://www.guardian.co.uk/society/2010/nov/12/bowel-cancer-drug-rejected-by-nice

1 comment

  1. adiba says:

    on-going medical advances in an endeveour to combat life-limiting or debilitating illness will enevitably produce better therapeutic agents. The simple fact is that pharmaceutical companies are primarily businesses and they will want to recover their costs as well as make a very healthy profit on top!. This in turn unfortunately results in novel agents that are sometimes out of reach for the NHS .
    Patents mean that it can be a number of years before any novel therapy can become accessible for the average patient. Maybe the way forward- if the NHS survives is to have more central funding for university based research so 1) we make university based research more attractive and don’t lose researchers to industry. 2) more capacity and funding for research would potentially allow universities to come up with more of their own novel agents and therapeutic applications. 3) the university based research should allow for a platform to be created making potential lnks with industry so a mutual exchange of information can occur and prices for manufaturing and purchasing could be negatiated.
    In a way for universities to be more business like with their research and think of research oucomes as potentially saleable products rather than just academic endeavers for the greater good?

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