The National Institute for Health and Care Excellence (NICE) has just released its second draft decision on radium-223. This time, they do recommend it be made available on the NHS for men with advanced prostate cancer that no longer responds to hormone therapy and has spread to the bones. But they only recommend it for these men if they’ve already been treated with chemotherapy.
The Scottish Medicines Consortium (SMC), which operates independently of NICE, hasn’t yet considered radium-223 availability on the NHS in Scotland. So at the moment men north of the border can’t routinely access it.
Radium-223 is a mildly radioactive version of the metal radium. It’s given by injections into the vein, where it travels in the blood system to the bones. It works a bit like calcium, and is taken up by active bone cells. But the radioactivity then kills these cells. Cancer cells are more active than normal bone cells, so they’re more likely to pick up the radium-223. This also means that the side effects are minimal, because healthy cells aren’t damaged. This treatment specifically targets prostate cancers that have spread to the bone, and the fact that it causes minimal damage to healthy tissue makes this an important step forward.
Way back in March, NICE said that they couldn’t recommend radium-223 be made available on the NHS. They said that Bayer, the pharmaceutical company who made the drug, hadn’t given them enough evidence of how well radium-223 performed compared to appropriate treatments currently available. Therefore they weren’t able to work out how cost-effective it was. In our press release, we called for Bayer to fix this problem as soon as possible, and give NICE the evidence they need to make a better decision.
So, on the one hand, it’s great that Bayer and NICE listened to us and worked together to get the additional evidence so that the first draft guidance could be revisited. We’re also really pleased that this extra evidence means that radium-223 will now be available on the NHS for some men with advanced prostate cancer that no longer responds to hormone therapy and has spread to the bones. This is especially good for men in Wales and Northern Ireland, who can't access radium-223 through England’s Cancer Drugs Fund until it is recommended by NICE.
But even though it’s nearly Christmas, we’re still looking this gift horse in the mouth and saying we’re disappointed the recommendation is limited to men who’ve already had chemotherapy.
Chemotherapy isn’t an option for all men with advanced prostate cancer. Some are too frail. Some want to delay the onset of the devastating side-effects that chemotherapy can bring. And others just simply do not want chemotherapy. In fact, 20-40 per cent of men with advanced prostate cancer that has spread to the bones never have chemotherapy. Radium-223 could provide precious extra months without reducing quality of life for these men.
Having said that, we expect that radium-223 will continue to be accessible before chemotherapy to men in England via the Cancer Drugs Fund, although men in Wales and Northern Ireland will still be denied this option.
NICE decided not to make radium-223 available before chemotherapy because they didn’t think it was as cost-effective as it would be after chemotherapy. This was a bit of an unfair comparison, to be honest, because in the group of men who hadn’t had chemotherapy, they measured the cost against ‘best supportive care’ (in other words no drugs), so it looked relatively expensive. But when they assessed its use after chemotherapy, they compared radium-223 to abiraterone (which is more expensive than no drugs), so radium-223 appeared relatively good value. Sounds to us like yet another negative repercussion of the decision to reject abiraterone before chemotherapy. We suspect that if radium-223 had been compared to abiraterone before chemotherapy too, its relative cost would have been more acceptable.
So we hope that NICE will once again work with Bayer to resolve these differences, so that all men who need radium-223 will be able to access it – whether they’ve had chemotherapy or not.