The National Institute for Clinical Excellence (Nice) has been criticised for ruling that Avastin is not cost-effective enough to be prescribed on the NHS. Photograph: Martin Argles for the Guardian
This week, the National Institute for Clinical Excellence (Nice) announced that it would not approve funding for Avastin – a cancer drug that can extend life by weeks or months. During the slow August news cycle, the decision set off a predictable firestorm. Nice was vilified, patient groups protested, and the government distanced itself from the story.
As is so often the case, the decision about whether or not to fund Avastin appeared as a choice between saving money and extending life. After 24 hours of heated debate, the story dropped off the radar. That’s unfortunate, because it didn’t allow us to have the kind of nuanced discussion that could offer answers for how to address these kinds of challenges.
The debate over Avastin oversimplified treating patients with a terminal illness, and seemed to suggest that having a good outcome boiled down to receiving a specific medication. However, new research suggests that there may be a better solution if we’re willing to have an honest discussion about terminal illness and palliative care. An August 2010 paper by Jennifer Temel and colleagues, appearing in the New England Journal of Medicine, explores the impact of introducing, in addition to traditional cancer treatments (like Avastin), palliative care in the early stages after a patient is diagnosed with terminal cancer.
The idea of promoting palliative care is not without controversy. While traditional medicine seeks to lengthen life, the aim of palliative care teams is to improve the quality of life for patients with a terminal diagnosis. Here, palliative care teams discuss with patients how they envisage their last few months, inform about and prescribe medications to lessen unpleasant symptoms, and counsel patients about their options.
Frequently, the medical community has viewed palliative care as a sign that nothing more can be done. To them, instinctively, palliative care goes against the basic goals of modern medicine and may hasten death. Discussing palliative care also forces medical staff to have difficult conversations with patients about the limits of medicine, death and terminal illness.
To the public, palliative care can be construed as code for saving money and an attempt to deny them aggressive therapy that could extend life. However, Temel’s paper suggests that this couldn’t be further from the truth.
In a randomised control trial, Temel’s team looked at two groups of patients who were recently diagnosed with terminal cancer. Half the patients underwent the standard cancer treatment, which included access to the latest medications (like Avastin) if they wanted it. The second half received the same standard cancer treatment and immediate access to palliative care.
Her team found that patients who received palliative care had a lower incidence of depression, less pain and more mobility. What’s more, they also lived nearly three months longer. These results alone are enough to suggest that paying for palliative care is a good idea. However, in addition to living longer and having higher quality of life scores, patients who received early palliative care consumed fewer healthcare resources.
Often these patients opted out of receiving aggressive treatment, and despite that decision, they survived longer. In short, it seems giving patients access early palliative care was able to increase the likelihood of people getting precisely what they often say they want out of their final months: it allowed patients to live longer, avoid suffering, reduce depression and minimise their burden on family and others. For better or worse, it also saved money.
This is not an easy topic. As medicine and technology continue to evolve and as science allows us to live longer, these types of debates are increasingly likely to become the norm.
However, this paper suggests that rather than debating whether to fund expensive cancer drugs, the NHS should fund the drugs and also actively encourage early and aggressive palliative care. This means we’ll need to have difficult conversations about life and death – but in the long term, it also means that patients will have more options and better outcomes and that the health service will be able to provide better care at a lower cost.