About 1,000 women a year in England with HER2-low advanced breast cancer can now get Enhertu. My lab measured the paperwork instead.
Enhertu is now available on the NHS in England for about 1,000 women a year with HER2-low advanced breast cancer. Dr Petra Voidwell reports this as routine and unremarkable. Her real concern is the sealed envelope containing the confidential agreed price, which her team has measured and declared load-bearing for the state.
The deal was signed on a Tuesday. The agreed price then went into a sealed envelope, and the envelope went into a drawer. My team has spent nine weeks measuring that drawer, and I am here to explain what we found.
First, the drug, since you asked. Around 1,000 women a year with HER2-low advanced breast cancer in England can get Enhertu on the NHS from Thursday. It extends their lives. That is the whole finding, and I am aware it is not much of a story.
We are fairly confident this is good. Further work is needed. I would not lead with it.
The envelope
The envelope is a different matter entirely. It contains a number that nobody outside the negotiation is allowed to see, which makes it the only object in England whose contents are load-bearing for the whole state. We measured it at nine centimetres by twenty-two. Our reading suggests the country is now built on it.
We kept nine identical empty envelopes in a cupboard as a comparison. A comparison group is the boring version of the thing you actually care about. Nothing happened to any of them, and two were used for a birthday card.
We then checked whether the difference was luck. It was not.
"People keep congratulating me about the medicine," said Graham Tulloch, who negotiates drug prices for a living and asked me to stop calling his office. "The medicine was never the hard part. The hard part was agreeing a figure and then agreeing that neither of us would ever say it out loud."
"If that envelope is opened, we lose the price. If we lose the price, we lose the deal. If we lose the deal, I have to start again, and I am nine years older than when I started."
I asked a nurse on a day unit whether she felt the weight of the situation. She said she was hanging an infusion bag and that the drug worked either way. I have logged this as an outlier. An outlier is a result you do not like.
The pattern here is simple and I would rather it were not. A treatment that lengthens thousands of lives arrives as routine business, reported in a paragraph, wheeled in on a trolley. The sheet of paper that got it there is guarded like a relic, sealed, unquotable, reviewed every few years by people who will not tell you what they are reviewing. My team ranked both objects for historical significance. The envelope won by a distance, and I want to be clear that I find this outcome depressing.
We recommend the drawer be checked every nine months. The women getting the drug this week will presumably carry on getting it.
They have not been told about the drawer. On balance, that seems kindest.
