title: Effect of the UK postcode lottery on survival of patients with metastatic renal cancer: an audit of outcomes in patients with metastatic renal cancer suitable for treatment with tyrosine kinase inhibitors.
abstract: OBJECTIVE
  To determine whether primary care trusts' agreement or refusal to fund sorafenib or sunitinib affects outcomes for patients with metastatic renal cell carcinoma.
  
  
  METHODS
  This retrospective audit was conducted in a tertiary referral centre for urological cancer. Requests to prescribe drugs not approved by the National Institute for Health and Clinical Excellence are recorded on a trust database. We obtained details of all requests made for sunitinib and sorafenib for patients with renal cell carcinoma since licence in 2006. Outcome measures analysed were overall survival measured from the date of request for funding and hospital resource use as measured from Payment by Results data. Known prognostic factors and the patient's Index of Multiple Deprivation score were assessed at baseline as potential confounders of survival difference.
  
  
  RESULTS
  Seventy-nine patients were identified. The groups were similar with respect to prognostic factors and Index of Multiple Deprivation scores. Thirty-seven and eight patients had funding approved for sunitinib and sorafenib, respectively; 21 and 13 were turned down. Seven patients who were denied funding received one or other of these drugs by self-funding treatment. Survival was longer for patients who received treatment with a drug for which they had applied for funding than for those who did not (hazards ratio 0.46; 95% confidence interval 0.21-1.01; chi(2)=3.80; 1 d.f.; P=0.05); the advantage was similar for patients receiving sunitinib (hazards ratio=0.49; 95% confidence interval 0.18-1.36; chi(2)=1.86; 1 d.f.; P=0.17) and sorafenib (hazard ratio=0.44; 95% confidence interval 0.11-1.69; chi(2)=1.58; 1 d.f.; P=0.21). Overall National Health Service resource use apart from funding for the renal cancer drugs was similar for both groups.
  
  
  CONCLUSIONS
  Compared with patients receiving treatment, patients denied access to sunitinib and sorafenib had substantially worse survival outcomes, despite receiving treatment from the same clinical team. Access to the new drugs did not have an effect on overall use of National Health Service resources by funded patients. Modern treatments for advanced renal cancer should be available to all National Health Service patients with the disease.
authors.affiliation: Cancer Centre, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2TH, UK.
authors.forename: N
authors.initials: N
authors.lastname: James
authors.forename: J
authors.initials: J
authors.lastname: Pascoe
authors.forename: A
authors.initials: A
authors.lastname: Zachariah
authors.forename: D
authors.initials: D
authors.lastname: Ray
authors.forename: A
authors.initials: A
authors.lastname: Oldroyd
authors.forename: H
authors.initials: H
authors.lastname: Parry
authors.forename: H
authors.initials: H
authors.lastname: Benghiat
authors.forename: M
authors.initials: M
authors.lastname: Karina
authors.forename: S
authors.initials: S
authors.lastname: Collins
authors.forename: E
authors.initials: E
authors.lastname: Porfiri
mesh_terms: D020533:Angiogenesis Inhibitors / Q000627:therapeutic use*; D001557:Benzenesulfonates / Q000494:pharmacology; D002292:Carcinoma, Renal Cell / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology*; D005260:Female; D006801:Humans; D007211:Indoles / Q000494:pharmacology; D007668:Kidney / Q000473:pathology; D007680:Kidney Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology*; D008297:Male; D008485:Medical Audit; D009362:Neoplasm Metastasis; D009536:Niacinamide / Q000031:analogs & derivatives; D010671:Phenylurea Compounds; D047428:Protein Kinase Inhibitors / Q000627:therapeutic use*; D011725:Pyridines / Q000494:pharmacology; D011758:Pyrroles / Q000494:pharmacology; D000077157:Sorafenib; D000077210:Sunitinib; D016019:Survival Analysis; D006113:United Kingdom
chemical_list: D020533:Angiogenesis Inhibitors; D001557:Benzenesulfonates; D007211:Indoles; D010671:Phenylurea Compounds; D047428:Protein Kinase Inhibitors; D011725:Pyridines; D011758:Pyrroles; D009536:Niacinamide; D000077157:Sorafenib; D000077210:Sunitinib