Two breast cancer drugs not cost effective, says final NICE guidance
The National Institute for Health and Care Excellence (NICE) does not recommend lapatinib (Tyverb, GlaxoSmithKline) or trastuzumab (Herceptin, Roche) with aromatase inhibitors for a particular type and stage of breast cancer, in final guidance published today (Wednesday 27 June) This is because it is unclear how much either drug can improve overall survival compared to existing treatments and they do not represent value for money for the NHS when used in these ways.
The guidance is specifically on the use of lapatinib or trastuzumab as first line treatment options to delay the growth of advanced breast cancer that has spread to other parts of the body (metastatic disease), and which reacts with the hormones oestrogen or progesterone and has high levels of a protein called HER2 on the surface of its cells. The guidance only advises on the use of these drugs alongside aromatase inhibitors (a type of hormone therapy).
Sir Andrew Dillon, Chief Executive of NICE said: “Having reviewed the available evidence, our committee of experts concluded that while both lapatinib and trastuzumab can reduce the growth and further spread of metastatic breast cancer tumours when compared with the aromatase inhibitors letrozole and anastrozole, the extent to which these treatments can improve overall survival appears to be small or difficult to quantify.
“Furthermore, independent economic analyses indicate that neither treatment combination appears to be cost effective for the NHS. Confidence in the additional benefits that new treatments provide is important both for patients and for those who have responsibility for managing the resources available to the NHS.”
The NHS Constitution states that patients have the right to receive all drug treatments that have been recommended by NICE for use in the NHS, if their doctor says they are clinically appropriate. A negative recommendation from NICE means that this obligation does not exist, although doctors can apply to the Department of Health's Cancer Drugs Fund if they believe either treatment will benefit their patients. Women with metastatic hormone receptor positive breast cancer which over-expresses HER2 who are currently receiving either drug option are able to continue treatment until they and their doctors consider it appropriate to stop.
For more information call the NICE press office on 0845 003 7782 or out of hours on 07775 583 813.
Notes to Editors
About the final guidance (TA 257)
1. For further information about NICE's technology appraisal of “lapatinib and trastuzumab in combination with an aromatase inhibitor for the first-line treatment of metastatic hormone receptor positive breast cancer which over-expresses HER2”, visit: www.nice.org.uk/TA257. Please contact the NICE press office for embargoed copies of this draft guidance.
2. Neither manufacturer submitted a Patient Access Scheme (PAS). Pharmaceutical companies can consider whether they wish to reduce the acquisition cost to the NHS of a drug by proposing a PAS to the Department of Health. If agreed by the Department of Health, a PAS may enable patients to gain access to high cost drugs if the new price that the NHS is asked to pay is found to be cost effective by NICE's appraisal process.
3. The Scottish Medicines Consortium has published advice for NHS Scotland, which does not recommend lapatinib or trastuzumab taken alongside an aromatase inhibitor for women with this particular type and stage of breast cancer. For further information, visit: www.scottishmedicines.org.uk
4. Estimates of the number of postmenopausal women diagnosed with this type and stage of breast cancer every year ranged from 50 to 2000. It is believed that most women with HER2 positive breast cancer are likely to be offered trastuzumab alongside chemotherapy as their first line option - this NICE appraisal does not look at the use of trastuzumab in this way. Lapatinib or trastuzumab would usually be considered as first line options alongside aromatase inhibitors only when chemotherapy is deemed unsuitable; however, it is unclear for how many women this would be relevant. Taking aromatase inhibitors in isolation is another existing option for these women.
5. Lapatinib is administered orally at a dosage of 1500mg (six tablets) per day. The acquisition cost for a lifetime of treatment of lapatinib plus the aromatase inhibitor letrozole (also taken orally) is £28,212 (£27,024 for lapatinib and £1188 for letrozole). This assumes a mean treatment-duration of 55.2 weeks and excludes administration costs.
6. This is the first time that NICE has published technology appraisal guidance on the use of lapatinib. This means that NHS decisions on the use of lapatinib outside of this appraisal are still made locally.
7. Trastuzumab is administered intravenously, either with a loading dosage of 4mg/kg followed by a weekly maintenance dose of 2mg/kg, or with a loading dose of 8mg/kg followed by three-weekly maintenance doses of 6mg/kg. Based on these, the acquisition costs for a lifetime of treatment with trastuzumab plus the aromatase inhibitor anastrozole (taken orally) are £26,018 (£24,852 for trastuzumab and £1166 for anastrozole) or £26,832 (£25,666 for trastuzumab and £1166 for anastrozole) respectively. These prices assume an average patient weight of 67 kg, a mean duration of treatment of 15 months, and exclude administration, monitoring and wastage costs.
8. NICE has previously recommended trastuzumab:
- In combination with paclitaxel for women who have tumours with excessive HER2 at levels of 3+ who have not had chemotherapy for metastatic breast cancer and for whom anthracycline treatment is inappropriate - www.nice.org.uk/TA34
- For women who have early-stage HER2-positive breast cancer after they have had surgery and chemotherapy and sometimes radiotherapy - www.nice.org.uk/TA107
- For HER2-positive metastatic gastric cancer - www.nice.org.uk/TA208
9. In terms of cost effectiveness, GlaxoSmithKline estimated that the most plausible incremental cost effectiveness ratio (ICER) for lapatinib plus letrozole compared to letrozole alone is likely to be nearer £74,400 per QALY gained. Roche estimated that the most plausible ICER for trastuzumab plus anastrozole compared to anastrozole alone would be in excess of £51,000 per QALY gained. Both estimates are significantly greater than the £20,000-£30,000 range that NICE would typically deem to be a cost effective use of NHS resources. For further information about how NICE measures cost effectiveness, visit the cost effectiveness webpage.
10. The committee concluded that neither combination treatment fulfilled NICE's ‘end of life' criteria. The ‘end of life' criteria are supplementary pieces of advice that committees consider when appraising treatments that may extend the life of patients with a short life expectancy and that are licensed for indications that affect small numbers of people with incurable illnesses. For further information, visit the NICE website.
1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health
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This page was last updated: 26 June 2012