Three in four UK breast cancer oncologists are still unable to prescribe cheap drugs that reduce the risk of the disease spreading to the bone, a new survey has found – amid a continued lack of guidance from the NHS on how to commission their use.
Bisphosphonates are low-cost, widely-available drugs normally used to strengthen bone in the treatment of osteoporosis and of cancer that has spread to the bone. But a ground-breaking analysis published in The Lancet over a year ago (July 2015) showed that they can reduce the risk of breast cancer spreading to the bone and elsewhere in the body in the first place, where it becomes incurable.
They could be taken by all post-menopausal women diagnosed with primary breast cancer – at least 35,700 women a year – and can reduce the risk of breast cancer spreading within 10 years from 21.2% to 17.9% (a relative reduction of 18%), reducing their risk of death from their disease in that time from 18% to 14.7% (a relative reduction of 18%).
If three quarters of this eligible patient population are not receiving bisphosphonates, this would amount to around 27,000 patients missing out.
Not all of these patients would see benefit from taking bisphosphonates. If given routinely to all eligible women in the UK, it is estimated that an extra 1,180 women each year could be prevented from dying from breast cancer – the equivalent of one in ten breast cancer deaths.
The drugs are estimated to cost on average just 19p each, and can be taken on average for three years, either as a daily tablet (ibandronate) costing 34p per day, or intravenously every six months (zoledronate) at 4p per day.
It is estimated that the total cost of the treatment (including consultant time and the cost of monitoring for subsequent possible side-effects3) is on average just 43p per day per patient.
But despite the overwhelming evidence of the clinical benefit of these cheap drugs for women diagnosed with breast cancer – and clear clinical support from UK breast cancer bodies such as the UK Breast Cancer Group and NHS England’s Breast Cancer Clinical Reference Group – there is still no clear national commissioning policy. This has led to difficulties for oncologists in prescribing them due to blockages in funding.
According to a new UK-wide survey of 125 leading breast cancer oncologists1 conducted by the UK Breast Cancer Group (UKBCG), less than a quarter (24%) of clinicians could routinely offer these drugs to their patients.
This is largely due to the lack of national guidance on who should fund them. For example, in England, it remains unclear whether it is the responsibility of the hospital trust or the local clinical commissioning group (CCG) to pay for these drugs for their patients, or whether it might be funded centrally by NHS England, as many cancer drugs are.
17% of oncologists said they had partially implemented the treatment, while an alarming 59% said they had not been able to offer it to their patients, with funding issues cited as the leading barrier.
Baroness Delyth Morgan, Chief Executive at Breast Cancer Now, said:
“While bisphosphonates are not routinely available to all eligible breast cancer patients, women’s lives are needlessly being put at risk.
“These are cheap and widely-available drugs and the overwhelming evidence of their ability to save lives should have changed practice by now. But they are still sitting on the shelf, blocked by bureaucratic inertia.
“We’re fortunate to have so many of the world’s leading oncologists working within the NHS, and we must ensure they have all the tools they need to offer the best possible breast cancer treatment.
“These barriers could be swiftly resolved and we’re calling on national NHS bodies to take the lead and finally give clarity on funding for these drugs through new national guidance.”
Furthermore, an assessment of the costs conducted by Breast Cancer Now, in collaboration with Professor Rob Coleman at the University of Sheffield and the South Yorkshire Cancer Strategy Group, shows that prescribing these cheap drugs to all eligible patients could actually save the NHS money in the long-term.
If all eligible patients received the treatment, the NHS would save £5m over 10 years for each year of patients treated:
- The cost of administering bisphosphonates (43p per patient per day) to this annual UK patient population (35,700 women) would be almost £17m, but these costs to the NHS would be off-set:
- in the short term, as this patient population would no longer need DEXA scans to monitor their bone density – an estimated saving of around £7m
- in the long term, by preventing around 1,200 of this group from developing secondary breast cancer, the NHS would (over a ten-year period) save more than £15m2
Professor Rob Coleman, Professor of Medical Oncology at the University of Sheffield, said:
“The clinical evidence demonstrating the benefits of bisphosphonates for postmenopausal breast cancer patients is convincing and based on many thousands of women treated in well-conducted trials across the world.
“It should be an absolute priority for every clinician and commissioner involved in the provision of breast cancer services to ensure this simple and safe treatment is made available, as a matter of urgency.
“Not only can they save lives but they would reduce needless expenditure on unnecessary tests and the ever-increasing costs of treating women with secondary breast cancer.”
Professor Ian Smith, Chair of the Breast Cancer Clinical Reference Group, said:
“It is deeply concerning that such an inexpensive treatment known to improve survival for women with breast cancer is not being made available to all that could benefit.”
“In order to deliver the best quality breast cancer care to UK patients, the introduction of these drugs for all eligible women must now be our top priority.
Dr Catherine Harper-Wynne, Consultant Medical Oncologist at Maidstone and Tunbridge Wells NHS Trust, and Secretary of the UK Breast Cancer Group, said:
“From our experience locally, we know that bisphosphonates can be easily incorporated into standard practice. It’s vital that clear financial guidance is now issued to enable this effective treatment to be introduced nationally.”
Breast Cancer Now wrote to NHS England in March to ask for clarity on the commissioning pathway for England, but is yet to receive a response. In light of the results of the UKBCG survey, the charity is now calling on national health bodies to take responsibility in ensuring bisphosphonates are made routinely available to all post-menopausal women diagnosed with breast cancer.
Breast Cancer Now calls on:
- NHS England to make a firm decision on who is responsible for commissioning bisphosphonates for breast cancer patients (either specialised services or CCGs), and to produce either a national commissioning policy, or guidance to CCGs
- NHS Wales to produce a national commissioning policy for Health Boards to follow
- Health & Social Care Services in Northern Ireland (HSCNI) to produce a national commissioning policy for Health Trusts to follow
1 It is estimated that the 125 oncologists surveyed accounts for more than half of all breast cancer oncologists in the UK.
2 There is no comprehensive up-to-date estimate of the total cost of a secondary breast cancer patient to the NHS. The best estimate currently available is £12,500 and this, from 2004, is likely to be a gross underestimate, so the savings are anticipated to be notably higher. Remak, E; Brazil, L (2004): Cost of managing women presenting with stage IV breast cancer in the UK, British Journal of Cancer 91, 77-83
3 Bisphosphonates are generally well tolerated, and most people experience only mild side-effects if any. Some people experience flu-like symptoms from intravenous bisphosphonates, and some people taking it orally can have problems like indigestion and nausea, but these generally subside. Serious side-effects are rare, but these include potential kidney damage, particularly from intravenous BPs, and dental problems such as osteonecrosis of the jaw (ONJ). Read more on the Cancer Research UK website