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In this edition we carry a number of articles relating to the treatment of cancers. These range from articles on new treatments and vaccines for cancer to the safe handling of cytotoxic agents and the treatment of anaemia associated with cancer. So what do all these diverse articles have in common apart from the general topic of cancer? They are all high-technology medicines and, generally speaking, high-cost ones. While cancer treatment involves high-cost medicines, the use expensive medicines is not the exclusive domain of this clinical area. In many disease conditions we are seeing the use of high-technology medicines, for example the use of antitumour necrosis factors (anti-TNFs) in rheumatoid arthritis. Furthermore, “old” medicines are being reformulated using new technology, for example, inhaled insulin. As these new technologies generally come at a high cost and tend to be used mainly in hospitals, we, as hospital pharmacists, are faced with the challenge of balancing cost and efficacy.
As pharmacists on the wards or as members of Drug and Therapeutic Committees, we have to balance cost and efficacy as part of our daily job. However, high-cost medicines present a particular challenge, as they are often associated with disease states with particularly high morbidity or mortality rates.
As professionals we want to do the best for our patients, but we also have to consider the impact of decisions on the rest of the organisation. No matter which healthcare system we work in, budgets are cash limited. Therefore supporting the use of a new high-cost medicine in one situation may mean funds are not available to deliver healthcare in another part of the organisation. Furthermore, by using a high-cost medicine in one patient, a precedent is set for using it in other patients. In a healthcare environment where more and more medicines are being used per patient, and the medicines we use are becoming increasingly complex, the decision whether or not to allow the use of a new medicine is becoming increasingly difficult. We cannot rely on the licensing of a new medicine to provide the steer on whether a medicine should be used, particularly when there is a range of medicines available. In the UK we have set up the National Institute for Health and Clinical Excellence (NICE) to give guidance on the use of new technologies, particularly where they come at great expense or are potentially controversial. However, this cannot cover everything and there have been a number of high-profile cases where individual patients have challenged the decisions of hospitals or primary care trusts not to use a particular medicine.
As hospital pharmacists we are generally expected to know the cost of medicines and are trained to make decisions based on evidence, but ultimately we are making a judgment on whether or not a new medicine represents “value for money”. When considering a new high-cost medicine, which perhaps improves survival for a few months, such as in the treatment of cancer, we are in fact putting a value on an individual patient’s life. Such decisions are extremely complex, and will differ depending on the society we live in. As governments increasingly expect healthcare providers, especially those that are publicly funded, to operate efficiently and within fixed budgets, there needs to be more open debate on these issues. Furthermore, universities need to teach undergraduate pharmacy students not only the law relating to medicines, but also expose them to these complex ethical dilemmas. Medicines have contributed enormously to the increasing life expectancy of our populations, but need to be managed carefully. I am reminded of a quote from Oscar Wilde: “The cynic is the man who knows the cost of everything and the value of nothing.” As pharmacists we must not become cynics.