In its first full drug appraisal, on the use of taxanes for treating ovarian cancer, the National Institute for Clinical Excellence has recommended use of paclitaxel, in combination with a platinum therapy, as the standard initial treatment following surgery (p716). This is a welcome step towards the abolition of the unfair system of "postcode prescribing" whereby access to expensive drugs, such as paclitaxel, depends on where a patient lives.
The NICE guidance (which the Government "expects the NHS to follow") is unlikely to cause clinical controversy, although it could produce financial problems for those health authorities that are not currently prescribing paclitaxel, or are prescribing it only for selected patients. At Guy's and St Thomas's hospitals NHS trust, in London, paclitaxel is used in ovarian cancer and accounts for £0.5m a year, or 20 per cent of the money spent on oncology drugs. This is much more than is spent on any other single drug in oncology.
The NICE guidance is based on clinical trial evidence that adding paclitaxel to regimens for treating ovarian cancer can improve progression-free and overall survival. The guidance will be reviewed in March, 2001. By then, there may be new data, including further results from the UK-based ICON-3 trial. Preliminary results from that trial, reported last year (PJ, June 5, 1999, p817), caused surprise in that, in contrast to earlier trials, there was no significant difference in overall or progression-free survival between a paclitaxel/carboplatin regimen and two standard regimens (single agent carboplatin and a combination of cyclophosphamide, doxorubicin and cisplatin). Data may also become available on use of docetaxel, a taxane not currently licensed for use in ovarian cancer. A trial comparing paclitaxel and docetaxel, both given with a platinum compound, is under way.
Some of the next NICE appraisals could well be more controversial. For example, the use of COX-2 inhibitors for treating musculoskeletal disease is on the NICE schedule for this year. There are now two COX-2 specific inhibitors on the market in the UK (see p717), offering the promise of greater safety - at greater cost. How will the NICE weigh up the evidence on who should be treated with these drugs?