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Lack of appropriate evidence forces NICE to turn down ovarian cancer drug in draft guidance

In draft guidance issued today (11 March) NICE's expert independent advisory committee has not recommended trabectedin (Yondelis, PharmaMar) in combination with pegylated liposomal doxorubicin (PLDH) as a treatment for ovarian cancer because of concerns over how well it works compared with the most commonly-used treatments.

This draft guidance is now with consultees who have the opportunity to appeal against the proposed recommendation. NICE has not yet issued final guidance to the NHS.

NICE has been looking at whether this combination treatment should be recommended for NHS use in patients with ovarian cancer that has returned six months or more after initial treatment with chemotherapy, which included platinum (i.e. for platinum-sensitive disease). The Appraisal Committee considered all available evidence, including clinical trial data submitted by the manufacturer and expert opinion from clinical specialists. It also took into consideration a Patient Access Scheme to make the treatment more cost-effective for the NHS.

Sir Andrew Dillon, NICE Chief Executive, said: “According to the clinical experts, re-treatment with platinum-based chemotherapy is the preferred option for relapsed platinum-sensitive ovarian cancer. The manufacturer of trabectedin did not submit any evidence comparing trabectedin with platinum-based chemotherapy, comparing it instead with drug regimens that did not include platinum. In platinum-sensitive disease, this type of treatment is usually reserved for patients who cannot have platinum-based drugs for reasons such as having had an allergic reaction to platinum in the past. This means that we cannot be sure that trabectedin extends patients' lives for longer than the most routinely used treatments.

”Our independent expert Appraisal Committee did look at other research to assess whether trabectedin should be recommended in the NHS. The manufacturer's main evidence compared trabectedin plus PLDH with PLDH alone in ovarian cancer patients with different levels of platinum sensitivity. Results suggested that the drug was most effective in women with ‘partially platinum-sensitive' ovarian cancer, which is when the disease recurs between 6 and 12 months after initial platinum chemotherapy. However, the committee could not be sure that the effectiveness of trabectedin in this group was genuinely different from that seen in the wider group of patients for which the drug is licensed and concluded that the subgroup data were not robust.

“Even when taking into consideration the Patient Access Scheme, through which the manufacturer limited the total cost of the drug, the committee concluded that the cost of trabectedin was too high relative to the uncertain benefits it may provide patients.”

Consultees now have until Friday 25 March to appeal against the recommendations via the NICE website; www.nice.org.uk. Until NICE publishes final guidance, NHS bodies should make decisions locally on the funding of specific treatments.

Ends

Notes to Editors

  • The guidance is available to view at: http://guidance.nice.org.uk/TA/Wave19/47 (from Friday 11 March 2011).
  • Trabectedin is an intravenous drug that works by damaging the DNA in cancer cells, making the cells unable to grow and spread. It is administered via a drip every three weeks with the recommended dose being 1.1mg per m² of body surface area.
  • The manufacturer estimated that the cost of treatment with trabectedin plus PLDH, assuming an average of six cycles and a body surface area of 1.72 m², is £23,917, excluding administration costs.
  • Taking into account the impact of all the uncertainties in the evidence presented to them, the Appraisal Committee considered that, for the entire platinum-sensitive population the incremental cost-effectiveness ratio (ICER) could be higher than £95,000 per QALY gained.
  • For the partially platinum-sensitive population (where the disease relapses between 6 and 12 months after initial platinum treatment), taking into account the Patient Access Scheme (whereby the manufacturer would pay the cost of trabectedin after the fifth cycle of treatment [that is, cycle 6 and beyond] for partially platinum-sensitive patients), the committee considered that the best estimate of the ICER was £68,000 per QALY gained.
  • Ovarian cancer is the fifth most common cancer in women in the UK[i] with nearly 6,600 women diagnosed with the disease each year[ii]. It is thought the cancer recurs after initial treatment in around 80% of cases and just over two fifths of these patients would be eligible for trabectedin, if the drug were to be approved[iii].
  • A range of treatments are already available on the NHS for patients with relapsed ovarian cancer. Published in 2005, NICE Technology Appraisal No. 91 recommends the following as options for second-line (or subsequent) treatment:

o paclitaxel in combination with a platinum compound in platinum-sensitive or partially platinum sensitive disease

o pegylated liposomal doxorubicin hydrochloride in partially platinum-resistant disease

o single agent paclitaxel or pegylated liposomal doxorubicin hydrochloride in platinum-resistant or platinum refractory disease or for those with an allergy to platinum-based compounds

o topotecan only where the other recommended options are considered inappropriate.

  • In 2010, NICE recommended trabectedin as a treatment for some patients with an advanced form of a rare type of cancer called soft tissue sarcoma. This guidance is available to view at: http://guidance.nice.org.uk/TA185.

About NICE

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

2. NICE produces guidance in three areas of health:

  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

  • quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
  • Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research andinformation to help health professionals deliver the best patient care through NHS Evidence.

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[ii] In 2008, the year for which the latest incidence figures are available, 6,597 women were diagnosed with ovarian cancer (sources: Office for National Statistics, 2011 Cancer Statistics registrations: registrations of cancer diagnosed in 2008, England. Welsh Cancer Intelligence and Surveillance Unit, Cancer Incidence in Wales. ISD Online Cancer Incidence, Mortality and Survival data. Accessed 2011. Northern Ireland Cancer Registry, 2011 Cancer Incidence and Mortality.

[iii] According to the manufacturer's submission, the size of the platinum-sensitive population for ovarian cancer is approximately 2,765 people

This page was last updated: 11 March 2011

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.