Vernon Harvey: Treatments extend beyond Herceptin

Each new statement about Herceptin leads to articles hailing it as the miracle cure for breast cancer, and is guaranteed to prompt yet another patient to ask me when it will be subsidised in New Zealand.

[The government drug-funding agent Pharmac has just said once again that Herceptin, which can cost more than $100,000 for each patient, will remain unfunded for those in the early stages of the disease.]

In many ways, breast cancer medicine is a victim of its own success.

Since the drug Tamoxifen was first used to fight breast cancer at the Christie Hospital in Manchester, England, in 1969, we have been able to transform women's chances of survival from this once-deadly disease.

There is no doubt that Tamoxifen has proved its worth as a means of stopping the spread or recurrence of the disease in women who have undergone surgery for a first breast cancer. And it has rightly been regarded for many years as the gold-standard treatment.

Patients and lobby groups naturally assume that the next front-page discovery will have an incremental efficacy.

But they often overlook the fact that not all new treatments are headline-grabbers and some may already be available on their doorstep.

The next generation of improved breast cancer treatments after Tamoxifen, the aromatase inhibitors, are available in New Zealand through a combination of government subsidy and special access schemes, designed by the pharmaceutical companies which manufacture them, to bridge the gap between funding applications and approval.

Yet there has been little fanfare about it.

When I ask my patients what they think will happen if they get Herceptin, they answer that their chances of survival will increase by 50 per cent.

When I ask them what will happen if they don't get it, the answer is that they will die. Neither of these is true. Medicine is seldom as black and white as the media would like to portray it, or as simple as our patients subsequently perceive it to be.

Herceptin is an exciting therapy for a particular type of breast cancer - cancers with positive HER2 receptors - but not quite the wonder drug portrayed in the media.

While it improves outcome for a specific, relatively small group of patients, it comes at a huge cost, which the patient must pay, as it is not yet funded by government.

One of the difficulties is that breast cancer is one of the most emotive subjects in medicine and, as such, is commonly used to illustrate the perceived failings of healthcare delivery systems in New Zealand, Australia and further afield.

And concern about the effects of budget restrictions, the cumbersome special authority system of approving subsidies and patients' rights to be involved in their treatment are all important points to consider.

Yet the arguments about whether or not Pharmac is able to fund Herceptin have perhaps obscured the fact that most countries that have a publicly funded health system struggle to provide some treatments and that New Zealanders have accessibility to some new treatment options for breast cancer just as early as the rest of the developed world.

The British authority has just recommended aromatase inhibitors for postmenopausal women with breast cancer who have undergone surgery.

And in Australia these medicines have only recently become fully funded.

Yet aromatase inhibitors are already available on subsidy in New Zealand for those patients with early hormone receptor-positive breast cancer and who have a history of intolerance to Tamoxifen.

One of these medicines, Letrozole (Femara), was recently approved as initial therapy after surgery for postmenopausal women with hormone receptor-positive early breast cancer.

The latest studies, partly conducted in New Zealand, showed that Femara reduced the risk of breast cancer recurring by an additional 19 per cent and reduced the risk of the cancer spreading to other parts of the body (distant metastases) by 27 per cent beyond the benefit found with Tamoxifen.

But for many of our patients it is only partly subsidised through the Pharmaceutical Schedule.

In response, pharmaceutical company Novartis has made Femara available to this group of New Zealand patients by removing the financial barrier of the part-charge, in partnership with selected pharmacies throughout the country, while continuing to negotiate with Pharmac about extending the subsidy to cover all the women who may need it.

We have here a medicine which further reduces the risk of the disease returning or spreading to other parts of the body.

It leads to fewer recurrences than standard Tamoxifen and also leads to fewer recurrences when given to women who have completed five years of tamoxifen.

It is an option at any time for patients who are intolerant of Tamoxifen.

The consensus is that treatment for all postmenopausal women with hormone sensitive breast cancer should include an aromatase inhibitor, unless they have contra-indications.

Whether those aromatase inhibitors should replace Tamoxifen or be used after some time on Tamoxifen remains to be seen.

This is good news for the 1200 New Zealand women who develop this kind of breast cancer each year.

* Vernon Harvey is an associate professor of oncology at Auckland Hospital