NICE approves abiraterone

The National Institute for Health and Clinical Excellence has now approved NHS funding of abiraterone for the treatment of castration-resistant metastatic prostate cancer.

Back in February, when NICE announced its preliminary decision to withhold approval, I wrote

So why has NICE announced a preliminary decision to withhold approval? It must be to give Johnson & Johnson the chance to make its offer more attractive. Probably not by anything as crude as cutting the price, but by some mechanism such as providing the drug free to any patient remaining on it beyond a specified length of time.

And NICE now says

The cost of abiraterone is £2930 for 120 tablets (excluding VAT; British national formulary [BNF] 63, March 2012). Abiraterone is administered as a single dose of 1 g per day, taken as four 250-mg tablets.The manufacturer of abiraterone (Janssen) has agreed a patient access scheme with the Department of Health. This involves a single confidential discount applied to the list price of abiraterone...

So there you have it.  The headline price of the drug is unchanged, the actual price charged has been reduced, and everyone is happy, apart from any patients who didn't get the best treatment while this slow dance was being performed.

Al-Megrahi

Abdelbaset al-Megrahi, the only person convicted for the Lockerbie bombing, died yesterday from metastatic prostate cancer, 33 months after he was released from prison on the grounds that his median life expectancy was less than 3 months.

First, my sympathies are with the victims of the bombing.

Second, I think it likely that al-Megrahi was not guilty as charged.  However, he does seem to have been an officer in Gaddafi's intelligence service: that's not in itself a crime but it does make it likely that his imprisonment was a sort of rough justice.

Third, the medical report supporting his release was poor.  All doctors' names are redacted in the published version, but it seems to have been written by Dr Andrew Fraser, chief medical officer for the Scottish Prison Service, who is not a cancer specialist.  And it seems that no expert in the treatment of advanced prostate cancer was involved in preparing the report.  (Karol Sikora, who is not such an expert, though he is an oncologist, was hired by the Libyan government to support al-Megrahi's release, and continued for some considerable time to agree with himself in the press.)  Unlike Dr Fraser, I consulted  a well-qualified expert (this was not long after al-Megrahi's release): she estimated his median life expectancy at two years.

Putting this all together, I suspect that the politicians responsible for the decision - Kenny MacAskill, the Scottish Justice Secretary, says that he's the one - also thought that al-Megrahi might well not be guilty, and found it expedient to commission a medical report supporting his release.  I do not accuse Fraser of acting dishonestly, but I do suggest that he was given the responsibility of writing the report because he was amenable to reaching the desired conclusion, and would not have to be dishonest in order to be wrong.