Presentation (CTI)

OBJECTIVES: NICE (England) and Canada's Drug Agency (CDA-AMC) appraise the same oncology medicines using a shared cost-utility framework with increasing collaboration (2023 NICE-CADTH-ICER Joint Position Statement) yet sometimes reach different reimbursement decisions. We examined why, and the implications for patient access.
METHODS: We reviewed the latest NICE technology appraisals and CDA-AMC reimbursement reviews, matched drug-indications across both and recorded the reasons they differed. Illustrative cases with discrepant outcomes were selected.
RESULTS: Since 2021, NICE has issued 481 Technology Appraisal guidance documents and CDA-AMC has published 505 reimbursement reviews. Although most decisions aligned, there were discrepancies in some. NICE rejected trastuzumab deruxtecan (HER2-low breast cancer) and pralsetinib (RET fusion-positive NSCLC), which CDA-AMC reimbursed with conditions. Conversely, tepotinib (METex14 NSCLC) was funded routinely and sotorasib (KRAS G12C NSCLC) via the Cancer Drugs Fund (CDF) in England, but neither were reimbursed in Canada. There were three reasons for discrepancies. 1) Comparative effectiveness; each agency weighed single-arm and indirect evidence differently, in some cases NICE accepting it but CDA-AMC judged the benefit versus standard of care unproven (tepotinib, sotorasib). 2) Cost-effectiveness; at NICE's lower threshold, the ICER was unacceptable even after discounting (trastuzumab deruxtecan, pralsetinib), whereas CDA-AMC issued conditional approval contingent on price reduction. 3) Structure; a managed-access route (CDF), handling of drug prices within versus after appraisal, and single- versus multi-payer systems resulted in different outcomes.
CONCLUSIONS: An oncology treatment can be available in Canada but not in the UK or vice versa based on identical supporting evidence. For patients, access also depends on reimbursement approaches and value thresholds, not only on evidence of clinical efficacy or cost-effectiveness. For pharmaceutical companies, a single evidence-package and pricing strategy may not satisfy both agencies. For health economists, harmonising methods does not guarantee aligned decisions as different assessors evaluate uncertainty differently.