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Prasad V. BMJ 2017;359: j4528 10.1136/bmj.j4528

Robertson E. BMJ 2017;359: j4568 10.1136/bmj.j4568

Nick Robinson, Radio 4's Today presenter and survivor of cancer, wrote 'No amount of courage no measure of cowardice can decide the outcome.' in a poem as a tribute to his friend and fellow broadcaster Steve Hewlett who sadly died of oesophageal cancer in February of this year. Hewlett's insightful diaries (https://www.theguardian.com > Society > Cancer), chronicled his journey with cancer. In these he touched on the cost of drugs for the management of cancer. With remarkable humour Steve Hewlett said he could 'probably afford this drug (£15,624 per monthly cycle for ramucirumab) provided it's not for too long. In other words, the sooner the treatment fails the happier my bank manager will be!'

A high impact paper (N Engl J Med 2016;375: 1856–1867) was published in the previous year that reported nivolumab, an anti-programmed cell death monoclonal antibody, increased overall survival for recurrent squamous-cell carcinoma of the head and neck from 5.1 months to 7.5 months. The National Institute for Health and Care Excellence (NICE) has not approved the use of nivolumab for the NHS. The cost of nivolumab would be between £66,000 to £75,000 per year of quality life with its ceiling being £20,000 to £30,000 per year (the Guardian, 11 Apr 2017).

This abstract highlights areas in two of four papers published in the same issue of the BMJ exploring the benefits and costs of cancer drugs. At their heart is a commentary by Emma Robertson, leader of Just Treatment. Robertson is afflicted with secondary breast cancer. She cites the independent drug bulletin Prescrire (monthly medical journal in French) that states 'only 7% of 1,345 therapeutic drugs assessed between 2000 and 2013 offered “a real advantage” when compared with drugs that were already available'. Yet the cost of such drugs has increased by 10% every year between 1995 and 2013. These drugs just take a share of their competitor's market. She argues for an approach that rewards and promotes innovation and breaks the link between drug prices and research and development costs.

And the Editorial sounds other notes of caution. It is stated: 1) the efficacy of the drug is usually modelled on estimates that 'are uncertain and seem to be consistently larger than measured gains', 2) these small benefits are typically observed in patients who are younger with less comorbidity, and 3) many of the outcomes for survival are surrogate markers that correlate poorly with true survival. This Editorial is complementary of the role of NICE in that it does not approve drugs 'that provide only marginal or uncertain benefits at high cost.'