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Good morning everyone Ash recently reminded us of the complex issues in this area and especially the data here:- Fojo T. and Grady C. How Much Is Life Worth: Cetuximab, Non-Small Cell Lung Cancer, and the $440 Billion Question. J Natl Cancer Inst, 2009; 101: 1-5 ) On the basis that a picture is worth a thousand words, attached is a recent cartoon from one of our UK national newspapers. All hope is not lost when the front page cartoonists start drawing reproductions of these dilemmas. Of course, and I know we all know this especially Ash, but the limited outcomes described for some new cancer medicines are necessarily based on the mean. And as has been described on this group before, we'd all hope (and so would our patients) to be at the right hand end of the survival distribution curve when we face those few dark moments in our lives of serious, perhaps fatal, illness. And of course the oncologists using these medicines also are hoping for a much-better-than-average outcome too, and they'd be right in thinking that for those who do better than the mean in the trials the cost effectiveness result for those patients would almost certainly also be much better than the mean. In the UK there are some innovative arrangements emerging or at least being proposed where there's an initial discounted price for the new medicine and then, if a clinical response is seen, the NHS pays for on-going therapy. My question for the group is whether worldwide anyone has experience of such arrangements, and especially the arrangements for defining the "clinical response"? I'd be happy for off-line responses, and I'll undertake to collate a composite response and post that. Bw Neal Neal Maskrey, National Prescribing Centre, Liverpool UK