Infinite costs wouldn't be Nice

There's been a bit of a furore over the last couple of days about a decision not to approve a drug for treating advanced bowel cancer, Avastin, on the grounds that it would not be cost-effective. This has led to a huge amount of criticism, and headlines ranging from the relatively sober to the Mail's hysterical "Betrayal of the cancer patients: Rationing watchdog accused of talking down wonder drug's power to save lives".

The decision (or guidance: in fact, the final decision has not yet been made, with the guidance subject to consultation and appeal) was made by the National Institute of Health and Clinical Excellence (Nice), which decides on the cost-effectiveness of treatments and whether they should be available to patients on the NHS. According to trial data submitted by the drug manufacturer, Roche, the drug can extend the mean lifespan of people diagnosed with advanced bowel cancer from 19.9 months on chemotherapy alone, to 21.3 months with chemotherapy and avastin. This is by no means a miracle cure or wonder drug. This is a six-week gain, but it comes at a cost: the drug costs up to £21,000 per patient.

Barbara Moss, a survivor of bowel cancer, appears in both the BBC and Guardian articles. The Guardian says:

Mrs Moss said the National Institute for Health and Clinical Excellence (Nice) had put a "value on life" after it said the price was too high for the extra benefit it gives patients

While Mrs Moss is quoted in both pieces as saying:

It seems immoral to me that, as a result of negative NICE decisions like this one, people's choice of living or dying depends on whether they can afford a drug, because it isn't available to them on the NHS.

It's difficult not to have some sympathy for this point of view. But someone has to put a "value on life" (or in fact, a thing called a Quality Adjusted Life Year, QALY). Otherwise Roche could come up with a life-saving drug that cost £1 trillion per patient, and the NHS would have to fund it because you "can't put a value on life". Ultimately, the question is not just about avastin. There is only a limited amount of money for the NHS to spend on drugs, so if avastin gets funded something else (with probably greater benefit) doesn't get funded . These are clearly not easy decisions to make, which is why we have Nice to do it in the first place.

My point here is not that Nice have necessarily got this right (I'm not qualified to judge), or even that the QALY approach is the best possible one. The point is that Nice is doing a difficult, unpopular and necessary job. Accusing them of betraying cancer patients, when what they're actually trying to do is get the greatest benefit from a limited budget, is not really helpful to anyone.

Bad cycling: I'm the champion (but I'm not very fast)

Last night was the Stockport Clarion club hill-climb, on the infamous Cat and Fiddle road between Macclesfield and Buxton. I rode in this event last year, and had a good ride on a clear and dry day with a good tailwind. I had high hopes of bettering the 26:00 I did last year, but things didn't go exactly to plan.

There's a webcam attached to the side of the Cat and Fiddle pub, which looks over the finish of the course at the road summit. I had a look at it yesterday afternoon, and there wasn't much to see except cloud and massive wagons heading over to Buxton with their fog lights on. It didn't look like a lot of fun. Once I got home, I was having serious second thoughts about the whole enterprise as I got ready for the 18-mile ride to Macclesfield, with the rain rattling the windows in my flat. But I made myself head out, leaving in absolutely filthy weather and gnarly traffic for a fun rush-hour jaunt through Stockport. The weather gradually cleared up as I got towards Macclesfield, and I arrived with about ten minutes to spare before the 7pm start.

Unfortunately, the start had been put back to 7:30, so I ended up waiting around in the cold for 40 minutes. Will, the timekeeper, didn't make it until just before 7:30 because he had to pick someone up from the airport. So, dispensing with numbers, the four riders who had shown up got going as soon as possible. The weather was now dry, but cool and windy. I decided to ride with lights in case it was cloudy at the summit. I went off number 2, and it was one of those days when you know it's going to be rough as soon as you set off. I hadn't had enough of a warm-up, and my legs just didn't want to have any of it. I didn't really get settled in until I was past Walker Barn and had done the most difficult bit. By then, the two guys behind me had already gone past, but I had caught up with my minute man. Emerging into the open country beyond Walker Barn, the gale-force tailwind came into play, and the middle section of the course was very fast. I even had to touch the brakes on some of the corners. Then the last climb onto the top: I almost got blown off the road on a cross-wind section, and struggled past the timekeeper in 26:36, 36 seconds slower than last year. But, with the only other Stockport Clarion rider being my minute man, who I had passed about two and a half miles earlier, I was the club hill-climb champion. This is nice, especially as I was several times hill-climb champion at my former club, Birdwell Wheelers, but there's no pretending that I was particularly quick. Several riders in the club would have put minutes into me had they ridden, but like the lottery, you have to be in it to win it. Jolan managed to capture a webcam image of us at the top: I'm the guy in the red shirt at left...


My reward was a long, windy ride home, mainly in darkness, but I got to see the sun go down over Fiddlers Ferry power station as I headed back down into Macclesfield.

Bad cycling: I get round in 27:45

Following my New Year's Day adventures, I haven't done as much bike racing as I hoped I would this year. I was away In Norway all of June for work, and then the Stockport Clarion evening time-trials took a break during July. However, the last three Monday evenings I've been out on the Chelford 10-mile course, in an attempt to get some race fitness for next week's hill climb on the Cat and Fiddle. My aim was to get under 28 minutes for 10 miles, which is pretty modest. After a horrible day in the first event, where I was recovering from a migraine and should probably have stayed at home, I clocked 29:30 and wasn't optimistic. But the following week was better with 28:24, and last night I cracked it, just about, with 27:45. For the first time in these 10s, there were actually a couple of people slower than me. It was a good night, dry and sunny with a light headwind on the slightly longer outward leg, and times were generally fast-ish. There was a 21-minute ride, which is pretty quick for such a slow course.

Coming into Chelford on the homeward leg, there was an electronic sign that gives a read-out of your speed. I was grovelling up the slight incline at a bare 21 mph, so the days when I could get under 25 minutes seem long ago. One of the other riders went through at 27 mph. Still, I felt good, and I'm looking forward to the Cat and Fiddle next week.

"Dr" Nancy Malik is spamming my blog again...

In the comments to a couple of old posts, homeopathic apologist and internet numpty extraordinaire Nancy Malik says the following:

Studies in support of Homeopathy published in reputed journals

1. Scientific World Journal
http://www.ncbi.nlm.nih.gov/pubmed/17982565

2. Lancet
http://www.ncbi.nlm.nih.gov/pubmed/9310601

3. Neuro Psycho Pharmacology
http://www.nature.com/npp/journal/v27/n2/abs/1395862a.html // Bacopa Monnieri for memory

I thought I'd have a quick look and explain why they're nonsense. Unfortunately, this hasn't proven to afford much in the way of intellectual exercise.

The first paper is by Graunke et al., and concerns, I kid you not, the treatment of tadpoles with homeopathic thyroxin. This is a well-known bad homeopathy paper. The tadpoles in the treatment group were more developed than those in the control group at the start of the experiment, so it wasn't much of a surprise that they were more developed at the end too. There is more discussion of this dreadful rubbish here.

The second paper is the famed Linde et al. meta-analysis, published in 1997. While this paper does say "The results of our meta-analysis are not compatible with the hypothesis that the clinical effects of homeopathy are completely due to placebo", there are some other things to bear in mind:

1. The paper also says "However, we found insufficient evidence from these studies that homeopathy is clearly efficacious for any single clinical condition".

2. A 1999 paper by the same authors, using improved methodology and including new trials, states that "It seems...likely that our meta-analysis at least overestimated the effects of
homeopathic treatments".

3. A subsequent meta-analysis by Shang et al., published in the Lancet in 2005, using further improved methodology concluded that the results were compatible with homeopathy being a placebo.

Finally, the third study, by Roodenrys et al. in the journal Neuropsychopharmocology, is not about homeopathy at all, but rather about herbal medicine. In homeopathy, remedies are typically diluted such that it is very unlikely that they contain any of the original material: there is no active ingredient. In the Roodenrys study, what is being tested is brahmi, an Indian herb, of which the paper says:

Studies have shown that the herb contains many active constituents, including a number of alkaloids and saponins, however, the major constituents are the steroidal saponins, Bacosides A and B.

So it isn't entirely surprising that brahmi might have some effect.

From this fairly cursory glance at the studies provided by Nancy Malik, it's clear that she is from the Dana Ullman school of evaluating journal articles. This involves finding some papers that superficially appear to support your position, and then spamming them all over the internet. Luckily, for this approach there is no need to understand the articles, or even to read them. For people who think that magic water is medicine, that would be rather too much to expect.