That healthcare budgets are facing significant challenges in covering the cost of innovative cancer drugs is not news – clearly new financing mechanisms are required urgently. Nevertheless, beyond prices, patients are facing long, drawn-out negotiating processes as well as a lack of understanding on the part of some healthcare providers when it comes to new treatment options and data, both of which delay access.
These are some of the conclusions that we, at the Swedish Institute for Health Economics, have drawn in our new Comparator Report on Patient Access to Cancer Medicines in Europe 2016. It’s not by any means the first of its kind, as initially we undertook a similar analysis in 2005, together with Professor Bengt Jönsson of Karolinska Institutet. At the time, it sparked off a major discussion about differentiated access to cancer drugs – in the UK, for example, this focused on postcode prescribing. Later reports have also focused on breast and lung cancer.
What is of great significance here is that the 2005 report reviews data as far back as 1995, meaning that today we now have a 20-year perspective on access to cancer medicines.
The methodology is also interesting because, instead of adopting a bird’s-eye view by looking at drug sales in relation to population, we have looked at people affected by the disease. Drug use in relation to mortality is the point here, as most drugs are indicated in a palliative care setting. It is the real world data that we considered thought-provoking, because the administration of drugs in an actual clinical setting is very different than that in clinical trials. So we made a conscious effort to push for accumulating data when people really have access to the drug – essentially clinical effectiveness rather than efficacy.
It has become clear that European health systems need urgently to collect real world/time data if they want to better target medicines, improve access and cut costs. Some already have a head-start: the UK has an impressive cancer repository; and there are also quality registries in Sweden – although here we have less information about treatment or metastatic disease. Further afield, in the US, the American Society of Clinical Oncology has created CancerLinq to harness big data on the disease – a model from which we could learn much. Across most of Europe, though, this type of format is lacking, to date.
Our report acknowledges the fact that there is a large disparity in what European Member States are able to spend on cancer care. If you look at overall spend, Member States are actually spending between 5-8% of health budgets on cancer care, but because of varying levels of GDP, the spend can actually differ by a worrying factor of 10 in some comparisons. The report also notes that so far the cost of cancer care has not sky-rocketed, but has in fact remained relatively stable. This has been achieved in part because we have managed to transfer many patients from in- to outpatient care, despite increased drug costs.
Of course, countries are using health technology assessment to help steer resources towards those drugs they believe to be cost-effective in cancer treatment. However, comparisons between countries work effectively on a list price – which makes cost-effectiveness difficult to achieve, because we do not see proposed discounts at this stage. Then there is another hurdle to overcome if we consider the use of double- or triple-branded technologies – so adding one drug on top of another. In such a scenario, the Quality Adjusted Life Year – used by HTA bodies to measure disease burden – may be totally occupied by the first drug, leaving no room for the added innovative products. So we need a new model.
Focusing on outcomes is doubtless a step in the right direction, but the idea that this alone can resolve the current access situation is questionable. The use of big/real world data is going to be of vital importance, as this will lead to better-targeted therapies. It is clear that other actions are going to be necessary as well. We need, for example, to understand the complexity of cancer care. This applies to manufacturers, authorities and healthcare professionals alike. For example, when we talk about metastatic melanoma, we are not talking about one drug, but a toolbox of drugs – they are expensive, but used in the right combination for the right patient, they might extend life by several years, over time turning metastatic melanoma into a chronic disease and eventually even leading to a cure.
If we are going to come up with solutions to the affordability and access questions, we will need to share best practice across Europe. I remain hopeful that we can find these solutions.0