received prior therapy. The submission included a budget impact assessment for ipilimumab therapy based on a cost per dose exceeding €20,000 and an average cost per treatment (four cycles) exceeding €85,000.
The National Centre for Pharmaco-Economics is identical in many ways to the UK system used to ration cancer drugs. The UK has the worst survival rates in many cancers for which records are kept. The NCPE decided that the probability of ipilimumab being cost effective over a willingness to pay range of €20,000/QALY (per quality adjusted life year) to €45,000/QALY was 0%. QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for being dead. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or have to use a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this. The NCPE decided that a minimum cost of 20,000 euro (limited to 10 years) per annum to preserve a life was too expensive for the HSE and Insurance Companies. NCPE estimated total costs at €4.8million - €7.4 million in 2012 increasing to €5.3 million - €8.2 million in 2016 and decided -"We cannot recommend reimbursement at the submitted price".
As was subsequently exposed by Professor John Crown, the actual cost of Ipilimumab would be substantially less than NCPE estimated. Professor Crown rightly referred to the cost of Ipilimumab as an 'Investment' and so it has come to pass. Health Canada has approved ipilimumab as a first-line therapy in adults with unresectable or metastatic melanoma. This means that Canadians with newly diagnosed advanced melanoma, regardless of the subtype, will be eligible to receive ipilimumab as their initial treatment. The long term savings both in human and financial costs cannot be overestimated. Invasive surgery with all the resultant costs has long been the first treatment for melanoma patients. The insurance companies who have refused to pay for ipilimumab on the recommendation of NCPE and subsequently dumped their customers back into the public system must be compelled to reverse their decisions.
The NCPE got it wrong because it failed to consider the opinions of eminent experts or to look at other factors beyond immediate outlay, ipilimumab was and is an 'investment' in cancer care, not a cost.