In the zero-sum game of allocating resources within a national health service, difficult decisions must be made, and initial guidelines issued by the UK National Institute for Health and Clinical Excellence (NICE) have once again provoked strong feelings among researchers, clinicians, campaigners and patients.

NICE has recommended against funding for Sutent (sunitinib), Avastin (bevacizumab), Nexavar (sorafenib) and Torisel (temsirolimus) in the treatment of metastatic renal cell carcinoma, judging that the improvement in progression-free survival does not justify the high cost of the treatment. The four drugs have been widely approved in Europe and the United States, and this ruling would mean that interferon remains the standard of care in the UK, even though only 25% of kidney cancer patients respond to this. One expert, Professor John Wagstaff from the South Wales Cancer Institute, stated that there would now be no point “accepting referrals of patients with metastatic renal cell cancer ... leaving only the option of palliative care” (http://www.independent.co.uk/ 7 Aug 2008).

The body bases its decisions on the cost per quality adjusted life year, but Professor Peter Johnson from Cancer Research UK is sceptical: “...in this case there is a clear separation between what NICE finds to be valuable treatment, and clinical and patient opinion” (http://news.bbc.co.uk/ 7 Aug 2008). However, Professor Peter Littlejohns, clinical and public health director at NICE, emphasizes the need to avoid other patients “[losing] out on treatments that are both clinically and cost effective” (http://www.independent.co.uk/ 7 Aug 2008).

The final decision will be made in early 2009, with patients already receiving treatment continuing to do so until that time. In the meantime, NICE has stated that proposals of reduced costs from the manufacturers are being considered.