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December 21, 2017

Private Eye Medicine Balls 1458 November 17, 2017
Filed under: Private Eye — Dr. Phil @ 11:22 am

The Private Cancer Lottery Part 2


If you have private health insurance and need treatment, should you accept a cash bung to use the NHS? Most insurers offer this, typically £7,500 in the case of a life-threatening cancer. This makes sense in cases where the NHS has access to treatment or expertise that would result in a better outcome, but the motive of the insurers is simply to save money. A standard course of radiotherapy might cost £15,000, with similar fees for surgery, and the new chemotherapy drugs average £75,000 a year . So insurers can save millions by bribing desperately ill patients to switch to state funded care.


Private insurance varies enormously in cost, depending on your age and the level of cover you want to pay for. If you’ve had it for many years, you will likely have paid far more than and lump sum being offered. If you’re in a company scheme, you might be tempted take the cash. But generally, private patients now go to the back of the NHS queue when they switch sides. The days when a consultant you’ve initially seen privately could bump you up the NHS waiting list are largely gone. So by offering you cash when you’re desperate, insurance companies know you may wait longer and get a worse outcome (although private hospitals are far from risk free – see Eye last).


Many patients opt to go private not just for speed of treatment and choice of consultant, but in the hope they’ll get access to, say, new technologies and cancer drugs that have yet to be approved by NICE and aren’t available on the NHS. This is worth it if they turn out to work, but there is always the temptation in private medicine for doctors to over-test and over-treat because they have a financial incentive to do so. And doctors are not helped by regulators who approve new cancer drugs on flimsy evidence. The British Medical Journal reported two studies recently. The first found that between 2008 and 2012 the US Food and Drug Administration approved uses for 36 cancer drugs without evidence of survival or improved quality of life. Only five were shown later to improve survival compared with existing treatments or placebo after a median of 4.4 years on the market.


In cancer drugs approved by the European Medicines Agency between 2009 and 2013, 57% (39 out of 68) had no supporting evidence of better survival or quality of life when they entered the market. After a median of 5.9 years on the market, just six drugs had been shown to improve survival or quality of life. And even when drugs do improve survival the benefits are often marginal. In the above study, of the 23 drugs that improved survival, 11 (48%) failed to meet the modest definition of “clinically meaningful benefit” set by the European Society of Medical Oncology. In another study, the median improvement in survival among patients treated with 71 drugs for solid tumours was just 2.1 months. And, says the BMJ editorial, ‘these small benefits of cancer drugs typically occur in trials conducted in unrepresentative patient populations—patients who are younger and with less comorbidity than average clinical populations When a marginal drug advantage is applied to a real-world population, a small benefit may vanish entirely because of the fine balance between risks and benefits typical of these agents.’ And the average cost is £75,000 a year.


Many cancer drug studies use surrogate outcomes, such as tumour shrinkage, hoping this will be shown to correlate with better survival at a later date. For patients who are terminally ill, have few other treatment options and don’t have time to wait for more research, then experimenting with unproven drugs may be worth it, particularly as part of an ongoing trial. But as one cancer specialist told MD; ‘Basically, we burn or poison patients to treat their cancer, and often both. In all the enthusiasm surrounding the newest cancer drugs and radiotherapy techniques, we have to remember these treatments cost loads, have very unpleasant side effects and can do far more harm than good.’


A plastic surgeon told me of a 96 year-old patient he was asked to see, who had developed a huge pressure sore largely because of the aggressive radiotherapy and chemotherapy he had received for metastatic cancer. ‘I just thought how unkind and unwise we have become.’ Private healthcare my offer you more treatment options than the NHS, but these rarely include palliative care. The temptation with cancer may be to be ‘treated to death’ rather than to be allowed to die gently. As one consultant told my step father; ‘Do you know why they put rivets in coffins? To stop the oncologists trying one last dose of chemotherapy.’ He opted for palliative care.