KEY POINTS:
The bitter reality of drug funding is that limited money is forever being applied to endless need. There will never be enough to go around.
The need is endless because pharmacological science is always coming up with new, improved medicines to address problems previously thought intractable or to improve outcomes being achieved by existing remedies.
It is in that light that we should consider this week's decision by the drug-buying agency Pharmac: it will not increase from nine weeks to 12 months the period for which it will fund the use of Herceptin, a drug for the treatment of some breast cancers.
The agency had been ordered to reconsider the matter after a group of women, dubbed the "Herceptin Heroines", took legal action alleging it had not conducted proper public consultation.
The discussion since the decision has tended to create the impression that Herceptin is a wonder drug. It is not. Extensive and robust studies of 12-month regimes suggest that, at best, 87 per cent of women get no benefit at all from it, and that as many as 100 women would need to be treated for the life of just one to be prolonged.
And those figures do not take into account the increase in illness and death from the drug's side effects, notably heart damage. Given the existence of persuasive, albeit small-scale, research suggesting that a nine-week course may be no less effective than a 12-month one and given the average $100,000 cost of a 12-month course, Pharmac's decision is not, as one critic described it, "shameful and inhumane".
It is a responsible and well-considered use of a scarce resource - public money.
Neither is it, as Pharmac's critics claim, a rogue decision out of step with world opinion. The prestigious medical journal The Lancet was sharply critical of Roche, the drug's manufacturer, for publishing research on Herceptin's efficacy that did not include "crucial" overall and disease-free survival data or information on cardio-toxicity.
Women and their families faced with the prospect of paying between $50,000 and $150,000 in the private system to extend their Herceptin treatment to 12 months are understandably dismayed by the decision. But that does not make it wrong. The fact is that the optimal treatment period is far from clearly established: Roche itself concedes that the question "remain[s] unanswered at this time". The evidence in favour of the efficacy of a 12-month regime came from trials that compared that period of treatment with no treatment at all.
Pharmac's claim that its decision is driven by science, not cost, is less-than-entirely accurate. Publicly funding 12-month treatment would increase the annual Herceptin bill from about $6 million to more than $35 million and almost double the amount spent on cancer drugs.
Every dollar spent on Herceptin is a dollar unavailable for spending on other medicines that are demonstrably more effective and deliver more bang for the tax buck. Those aggrieved by the Pharmac decision need to consider who they would choose to deny treatment to, so that they can have more of a therapy whose effectiveness is so widely questioned.
National's associate health spokeswoman Jackie Blue says a National-led Government would "free up funds" for 12-month treatment, but such promises in an election year deserve to be treated with caution. She is plainly following the example set by her boss, who is fond of making bold and expensive promises with no explanation as to how they will be funded and she needs to say where the extra $30 million is coming from.
She should also explain how she would ensure that the funds freed up would be used to extend Herceptin treatment. Pharmac is protected by statute from being directed by politicians. If it had another $30 million in the kitty, it would undertake a new budgeting exercise - and, on the basis of the evidence available to it, would likely find somewhere else to spend the extra money.
