Keytruda, Pharmac, and the zero sum game of drug funding

The human appeals for drug funding are heartbreaking. But we need somehow to put emotion to the side, and allow the experts to weigh up the evidence.

In recent days, the campaign to have the government fund Keytruda has stepped up again. A petition was yesterday delivered to parliament, with 11,000 signatures, from 11,000 very concerned people. They are totally justified to be concerned. For a small number of people, this is a very worrying case. There is no doubt we need better treatments for people with late-stage melanoma, and that clinicians, pharmacologists, and drug companies the world over are working on this every day. However, the way the story has been reported has at times left a lot to be desired, both medically and politically.

Keytruda is the market name of Pembrolizumab, a monoclonal antibody that targets the PD-1 receptor. Monoclonal antibody drugs are all the rage at the moment. They are highly specific, and can be used to target very specific cellular processes within particular cell types. With most monoclonal antibody drugs, they will be very effective for a subset of people with a type of disease. This is the case with pembrolizumab, which is effective in around one out of three cases of melanoma. For those people, it can be very effective; for the remainder, it will have no effect at all. On the basis of the evidence available at the time, Pharmac decided that it wasn’t appropriate to fund the drug.


Last week, Checkpoint interviewed two people people with advanced melanoma for more than 10 minutes. We were told that the Minister of Health wasn’t available, which was disappointing. However, some more balance could have been achieved by talking to a specialist, whether they be a doctor or a cancer researcher. This didn’t happen. John Campbell said that a representative from Pharmac would be on the next day, and so they were. The representative responded to Campbell’s questions in pretty much the only way she could – by calmly, repeatedly telling JC that they were doing the only thing they could do, within the bounds of the legislation.

The Keytruda case is very similar to the Herceptin one in 2008; a monoclonal antibody drug that was funded by going around the Pharmac process. This was one of National’s campaign promises in the 2008 campaign, and I’d argue it was one of the single worst decisions that they have made in the health portfolio. In listening to the interview on Morning Report yesterday with the other JC, health minister Dr Jonathan Coleman, it seems that he agrees. The number of these very expensive, highly specific monoclonal antibody treatments is only going to increase. As our population lives longer, and has higher expectations of the health system, this pressure is going to keep increasing. Continual lobbying – from support groups, drug companies, and opportunistic political parties – will see the world-renowned Pharmac model undermined, possibly critically.

My doctoral thesis is looking at the molecular biology of endometrial cancer, so while it’s something I know a bit about, I’m not an expert on this. Do you know who is an expert? Pharmac. Instead of trying to tell people who know more about this what to do, we should be arguing for more funding for health, some of which will go to Pharmac. The health minister and the prime minister have indicated there will be a funding boost, and that a melanoma drug will be funded. This can only be good news, especially, of course, for those suffering from advanced form of the cancer. But the reality is, even if Pharmac did get another $30m or so, there is no guarantee that they would choose to fund Keytruda. They would go back to their team of experts, and decide how that money could best be spent, to increase the health outcomes for the most people.

The problem with having this fight in this public fashion is that it pits very sympathetic people with heartbreaking conditions against nameless bureaucrats and heartless ministers. Anyone would side with the cancer patients. But the people who aren’t in this equation are the people whose treatment would have to be defunded. This is a zero sum game, and to fund one treatment, you have to defund another. What if funding Keytruda for a hundred people led to a thousand people losing their only medicine for Parkinson’s disease? To pitch one group with disease A versus a group with disease B would be an horrific spectacle, if we did have to watch it play out in public. So we don’t. We trust that a group of medical and pharmacological experts will weigh up all of the evidence, and come to conclusions for us. As hard as it is, especially for those with these conditions that are currently without funding, we need to put emotion to the side when deciding how to spend our very limited health budget. The political debate around this should focus on the amount we spend on drugs, not which specific drugs are funded. We can either have these expensive, next generation medicines, or we can have one of the lower tax rates in the OECD – but we can’t have both.

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