Elite treat

On the way into work last Friday, I was listening to John Crown, consultant oncologist, former senator and all round talking-head, waxing angry about a novel cancer treatment that was not being offered to Irish patients who were hirpling along with metastasized melanoma. A diagnosis of the skin cancer known as malignant melanoma is decidedly ungood news. But if you have something black and ugly on your skin you want to get to your medico immediately because early treatment and diagnosis is the key to survival. If you ignore it, it won't go away but will send scouts the length and breadth of you body to set up malignant colonies.  If caught early, surgical removal of the obvious lesion and some mop up treatments gives you a good chance of living longer.  But you should definitely take it as a warning and wear a hat, long sleeves, factor gazillion sun-block, if you have to be outdoors in the Summer. It is clear that UV light especially the short-wavelength UVA may damage the DNA of your skin cells and trigger their uncontrolled growth. You should also warn younger members of your family to do likewise because they are likely to carry one or other of the handful of known genetic variants associated with the disease. A lot of these are known as 'tumor-suppressor genes' because the 'normal' form usually deals effectively with the UV damage and mops up wannabe cancers before they can be seen with the unaided eye.

Malignant melanomas have ballooned in recent years, increasing 2-3% year-on-year among over-50s in the USA.  Despite being riddled with the 'wrong' version of the various tumor-suppressor genes, the Irish did not much fall prey to this dread disease in times past: a) there isn't enough sun to get sunburnt b) bare flesh (even exposing the arms or legs) was frowned on my the moral-police c) naked bonking in hayricks never happened. It was a different matter entirely when a pale-skinned, red-hairs, freckly gasún or cailín went out to Australia. Wearing a hat wasn't part of their culture, sun-block hadn't been invented, and the sun beat down on them without pity. So melanoma was much more common in those emigrants than among their stay-at-home cousins.

Mr Crown's case was that Pembrolizumab a Merck product marketed as Keytruda, would save the lives of  some dozens of Irish people whose  got to treatment for Mal Mel too late, or had bad genes or bad luck and are now at late-stage metastasized melanoma for which the prognosis is very poor if left untreated.  Crivens, it's saved the life of 91 y.o. ex-President Jimmy "Guinea-Worm" Carter [prev].  Indeed prognosis is effectively a synonym for curtains and that patient will almost certainly become one of this year's crop of 140 people scythed to the grave by this disease. Pembro [we're on first name terms now] is super-elegant in its mode of action - it gees up the immune system to do its job more effectively.

With the consummate rhetorical flourish which we expect of consultants, senators and talking heads, Crown asked [I paraphrase] "What is the hold up, here? I have patients who have exhausted all other treatment options. The National Centre for Pharmaceutical Economics NCPE has made the calculations and given approval. Is it that politicians have been so prim about forming a government that there is no direction from the new Minister of Health?".  I didn't know that we had a NCPE, let alone that it employs sixteen [16!] people.  Nice work if you can get it but, like its sister quango the Food Safety Authority of Ireland FSAI [prev], there are no current vacancies.

What the NCPE do is some sort of QALY analysis [prev] to determine if the costs [$150,000 /yr!] of a course of treatment outweigh the benefits [another year's life for one person, and much glee among the sales department and share-holders in Merck]. I'm going to guess that, at a minimum, 140 people are in line to take up this drug before they join the crop of dead for 2017. Actually, it will be more because the oncologists will surely want to apply the treatment, which is demonstrably effective as early as possible after diagnosis.  But let's be conservative here: 140 x $150,000 = €20 million. That's 60 affordable social-housing units for families which are currently sleeping on blow-up mattresses in a hostel for homeless men.  But I only mention that emotive statistic because that's what The Media have been talking large about since the election . . . when they aren't talking emotively about Freeing the Water - we Freed the gays last year. YMMV, like one of those choose your own adventure books from the 1980s. Have tried the one called Realekonometrika?
Q. You have €20million at your disposal do you want to:

• Build 60 3-bed semis in outer Dublinia
• Buy another year of life for some red-headed over 50s 
• Treble your money by depriving the haemophiliacs of their free Factor VIII

Now here's a more radical idea, if the NCPE's QALY analysis has given the go-ahead for Pembro and [therefore?] the Health Service Executive HSE undertakes to spend €150,000 of tax-payers' money on a red-headed grandmother with stage IV metastatic melanoma then that €150K is gone west. Why don't we ask the granny, under informed consent, if that's what she'd like the HSE to do with her windfall? It looks like 2/3 of patients treated with Pembro don't survive 'progression free' for six months BUT that means that 1/3 of them do so survive which is about twice the odds compared to conventional chemotherapy. I dunno about you, but if I was faced with those odds I'd ask humbly to find me an ice-flow to sit on and could you please put the money towards the college fund of my bright-as-a-button but poor-as-a-church-mouse grand-daughter. It's Lombard Street to a china orange that the HSE will not accede to this request because they are wedded to pushing money at big pharma.