Global Comparator Report on Funding and Access to Oncology Drugs with special reference to South Africa

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Global Comparator Report on Funding and Access
to Oncology Drugswith special reference to South
Africa

• Dr Nils Wilking
• Karolinska Institutet, Stockholm, Sweden
• October 6, 2007.

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The 2007 report An up-date and extension of the
2005 European report

• A global comparison regarding patient access to
  cancer drugs
• B. Jönsson1 N. Wilking2
• 1Stockholm School of Economics 2Karolinska
  Institute, Stockholm, Sweden
• Annals of Oncology 18 (Supplement 3) 2007
• The report looked at access in 25 countries
• 19 countries in Europe
• United States, Canada, Japan, Australia, New
  Zealand and South Africa
• Total population 984 million
• The European countries included in the study
  constitute 76 of the European population (447
  million)
• Data on South Africa from a sub-report in
  manuscript.

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Key points

• Incidence is increasing while mortality is
  constant or declining
• Progress in medical treatments has meant that
  cancer is becoming a chronic condition, incurable
  but treatable. However, these benefits are only
  realised once the drugs get to the patients.
• There are great inequities between countries in
  the uptake and use of these drugs.

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South Africa. Cancer numbers. 1997-1999

• Most common Cancers
• cervical cancer
• Breast cancer
• Prostate cancer
• Lung cancer
• Oesophageal cancer
• Kaposis sarcoma

• Incidence
• 15-9/100 000
• Mortality
• 8-9/100 000

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Incidence of cancer in females in selected
countries (Canada, Czech Republic, Denmark,
Finland, New Zealand, Norway and Sweden) given as
age-standardized rate per 100.000 inhabitants.
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Incidence of cancer in males in selected
countries (Canada, Czech Republic, Denmark,
Finland, New Zealand, Norway and Sweden) given as
age-standardized rate per 100.000 inhabitants.
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Mortality of cancer in females in Norway, Poland,
Portugal, Spain, Sweden, Switzerland, United
Kingdom and the United States of America given as
age-standardized rate.
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Mortality of cancer in males in Norway, Poland,
Portugal, Spain, Sweden, Switzerland, United
Kingdom and the United States of America given as
age-standardized rate.
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Incidence of breast cancer in Canada, Czech
Republic, Denmark, Finland, New Zealand, Norway
and Sweden given as age-standardized rate.
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Mortality of breast cancer in Norway, Poland,
Portugal, Spain, Sweden, Switzerland, United
Kingdom and the United States of America given as
age-standardized rate.
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Causes of Death and Disease Burden
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The ten disease groups with largest disease
burden in South Africa, with statistics for Czech
Republic/Hungary/Poland and the E-13 countries
presented for comparison (2002 data)
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Cancer in developing countriesThe Size of the
Problem
The incidence of cancer is lower in countries at
a lower level of economic development, but they
account for more than half of global cancer and a
higher fraction of patients die
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Estimates (Africa) Adopted from Dr Ian Magrath
Actual deaths Deaths per 100,000
Tuberculosis 587,000 81
Malaria 900,000 124
AIDS 2,400,000 331
Cancer 506,111 70
Cancer is rapidly increasing, but is neglected,
compared to infectious diseases
These diseases interact, increasing further the
burden of disease
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Crude Rates by Regions Adopted from Dr Ian
Magrath
More affluent regions have higher actual
incidence and mortality rates and lower
mortality incidence ratios
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ASR (World) by region Comparison Effect of Age
Adopted from Dr Ian Magrath
Adjustment of rates to a world standard
population shows that incidence rates would
remain lower but mortality rates would increase
in low income regions as populations age
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The Global Pattern of Cancer Contrasts
Males INCIDENCE INCIDENCE MORTALITY MORTALITY
Crude ASR Crude ASR
N. America 530 398 210 153
W.Europe 526 326 295 174
Middle Africa 78 142 66 121
South Central Asia 76 106 55 78
Globocan 2002
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Less and More Developed Crude Incidence versus
Cases Adopted from Dr Ian Magrath
Per 100,000 per annum
Thousands per annum
2002
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A Neglected Health Problem in Low Income
Countries Adopted from Dr Ian Magrath

• Cancer causes more deaths globally than AIDS,
  malaria and TB combined
• In 2002, gt50 of the 11 million estimated
  patients with cancer and 70 of cancer deaths
  were in developing countries, which have perhaps
  5-10 of global resources
• Developing countries will account for an ever
  increasing fraction of the global cancer burden
• The WHA has approved a resolution (May 2005)
  recommending that countries develop and implement
  cancer control plans

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Cancer Registration From CI on V Continents
I-VIII Adopted from Dr Ian Magrath
Fraction of World Population
149 5 60 11 1
Number of registries does not accurately reflect
population coverage (e.g., African registries
cover approx 7 million of the 888 million people
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Conclusions

• Cancer services are limited and already
  overwhelmed in developing countries in spite of
  relatively low cancer burden
• The cancer burden will increase markedly in the
  next decades (150m 2000-2020)
• Building human capital is a priority, but
  obstacles include pool of teachers, losses of
  personnel to better circumstances (internal or
  external)
• Material shortages facilities, equipment, drugs
  etc. and poorly structured health services
  compound the problem
• Poverty, illiteracy, stigmata, traditional
  healers create additional obstacles to care

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Direct and indirect cost of cancer

• Cancer accounts for about 5 of all health care
  expenditures in the USA
• The share for cancer has been stable over the
  last 30 years
• Cost of hospitalisation is the dominating cost
  item
• Indirect costs in terms of lost production is
  more than double the direct health care costs

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Direct costs for cancer care in selected
countries in 2004. Costs are PPP (Purchasing
Power Parity) adjusted.Total in million euro,
per capita in euro, and share of total health
care costs()
T
Europe 56 664 125 6.4 ()
United States 62 321 212 4.7 ()
Canada 5 013 157 6.7 ()
Japan 19 750 155 9.3 ()
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Cost of cancer drugs in perspective

• 2-2.5 new drugs per year since 1995
• Drug costs increase by 15-20 per year
• 3.5-7 of total drug expenditure are cancer
  drugs.
• Cancer drugs account for a minor, but growing,
  part (10-15) of total cancer care expenditure

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Total cancer drug sales
Total cancer drug sales (000s) in all 25
countries. 1995-2005 by year of first world wide
launch. Source IMS Health, IMS MIDAS Quantum
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Limitations in Resources Anti-Cancer Drugs
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Approval of cancer drugs
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Limitations in Resources for RadiotherapyAdopted
from Dr Ian Magrath

• In Dec 2004, there were approximately 2500
  radiotherapy centers and 3700 machines for cancer
  therapy in the developing world (enough for 1.85
  million patients per year compared to 3 million
  who need it.
• Maldistribution worsens the situation many
  countries have one machine for millions of
  patients (1 per 250,000 in high income
  countries). Over 20 countries mostly African -
  have none (IAEA).
• Many existing machines are idle for lack of
  maintenance, expired sources or lack of
  radiotherapists or physicists
• Old cobalt sources require longer radiation times

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• Inequities between countries in the uptake and
  use of these drugs

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PPP-adjusted per capita cancer drug sales () in
22 of the study countries in 2005.Distributed on
drugs of different vintage
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PPP-adjusted per capita cancer drug sales () in
2005 (For South Africa sales per capita is
presented also with two capita rates for the
total population as well as for the insured part
(18.5) of the population
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Gemcitabine uptake in Czech Republic, E13,
Hungary, Poland, South Africa insured pop., South
Africa total pop. and the UK
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Imatinib uptake in Czech Republic, E13, Hungary,
Poland, South Africa insured pop., South Africa
total pop. and the UK
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Rituximab uptake in Czech Republic, E13, Hungary,
Poland, South Africa insured pop., South Africa
total pop. and the UK
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Trastuzumab uptake in Czech Republic, E13,
Hungary, Poland, South Africa insured pop., South
Africa total pop. and the UK
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In many countries new drugs are not reaching
patients quickly enough

• Austria, France, Switzerland and the US are the
  leaders in the use of new cancer drugs, with
  France replacing Spain among the top four since
  the 2005 report was published.
• Uptake of new cancer drugs is low and slow in
  New Zealand, Poland, Czech Republic, South Africa
  and the UK.

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Questions to be sorted out

• Is improved cancer survival related to access to
  cancer drugs?
• or to early detection change in biology and
  diagnosis surgery and radiation therapy?
• Does survival improvement in clinical trials
  translate into survival effects in a population
  with cancer?
• If yes How do we measure this?
• If no Then we have a real problem

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Contribution of the increase in cancer drug
vintage to the decline in the age-adjusted cancer
mortality rate. Frank Lichtenberg Columbia
University, NY,NY.
Increase in drug vintage accounts for 30 of the
1995-2003 decline in the age-adjusted cancer
mortality rate.
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Actions proposed

• Give us better data!!
• Move from 10 year old epidemiology data to real
  time data on Impact of Preventive, Diagnostic
  and Therapeutic Interventions (iPDTi)
• Common medical view on risks and benefits
• Post marketing studies
• CRT or non-interventional trials
• Special budget for innovative treatments
• Take a global perspective
• Cancer in the developing countries will be a
  major challenge.
• Re-think price and volume

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Final comments

• Patients should have equal and early access to
  innovative treatments
• Research on access of therapy is an important
  part of cancer research

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