Gastric and oesophageal combined make up the fifth most common cancer in Ireland after prostate, breast, colorectal and lung cancer. In 2006, there were 820 cases diagnosed accounting for 5% of all invasive cancers (excluding nonmelanoma skin cancer) cases and 8% of cancer deaths in Ireland [1]. The disease has an approximately 20% 5-year survival rate in Ireland, similar to rates in other European countries [2] with one-third of patients presenting with advanced incurable disease at diagnosis. Current treatments include surgery or chemoradiation in the case of early disease, or chemotherapy alone for advanced disease. Many patients will receive a combination of treatment modalities. A study has shown that a proportion of these cancers tests positive for HER2, a receptor tyrosine kinase. Patients treated with trastuzumab (a HER2-targeted therapy) combined with chemotherapy had a better overall survival with a median gain of 2.7 months. A subset analysis based on patients with HER2 3? on immunohistochemistry or HER2 2? with gene amplification, and accounting for 17% of patients tested, had the bulk of the benefit with a 4.2-month improvement in median overall survival [3]. The cost of this treatment is, however, significant. The authors analysed the patients who are potentially eligible for this treatment in a single university hospital in Ireland. In 2006, 166 gastric and oesophageal cancers were diagnosed in our centre, accounting for 20% of the national patient cohort. Thirty-eight percent of the cohort (63 patients) had advanced disease at diagnosis (stage 3 or 4). If 17% of those patients were positive for HER2, as per ToGA post hoc analysis, then 11 patients could be considered for treatment with trastuzumab. The estimated drug cost per year would therefore be €24,000 per patient based on a median eight cycles of treatment, or €264,000 additional drug cost in one institution (Fig. 1 below). In Ireland, 820 patients were diagnosed with gastric or oesophageal cancer in 2006 and this increased by almost 5% in 2007 to 857 patients [4]. If 66% of those were OGJ/gastric tumours and a further 38% of those locally advanced, then 206 patients in Ireland would yield 35 with HER2 positive disease. The Irish national drug cost to treat these patients with targeted therapy would therefore be over €800,000 per year (Fig. 2 below). A QALY (quality adjusted life year) is defined as a year of life, adjusted for its quality or its value. Assuming the quality of life of a patient is the same on chemotherapy or a combination of chemotherapy and trastuzumab [5], and the median survival of 4.2 months or 0.35 years, thus the treatment has a QALY of 0.35. To calculate the cost per QALY, we use the following formula, (c1 c2)/(q1 q2), where c1 is the cost of the new drug, and c2 is the standard drug cost. q1 and q2 are the QALY for the new and old regimens, respectively, and in this case are the same. At a cost of €24,000 per patient for those 0.35 QALYs, this gives an incremental cost effectiveness ratio (ICER) of €68,000 per QALY. In the UK, the current NICE (National Institute for Clinical Excellence) threshold for cost effectiveness is *€60,000, though it may be higher in the palliative setting. I. M. Collins (&) K. O’Byrne Department of Medical Oncology, St James Hospital, Dublin 8, Ireland e-mail: Collins.ian@gmail.com