21 February 2019

South Africa: Cancer Drug Pricing Gets in the Way of Treatment in Developing Countries

analysis

Most cancers can now be detected early. This hasn't always been the case. The first big breakthrough came 80 years ago when the pap smear was introduced. Ten years later the mammogram was created and then nearly half a century ago the fecal occult blood test was developed.

Advances in diagnosis have made a huge difference. When cancer is detected at an early stage - and when coupled with appropriate treatment - the chance of survival beyond five years is dramatically higher. Early diagnosis can also reduce the cost of treatment.

Despite this, millions of cancer cases are found late. This results in expensive and complex treatment options, diminished quality of life, and avoidable deaths.

The global cancer burden is estimated to have risen to 18.1 million new cases and 9.6 million deaths in 2018 up from 12.7 million new cases and 7.6 million deaths in 2008. One in 5 men and one in 6 women worldwide develop cancer during their lifetime, and one in 8 men and one in 11 women die from the disease.

Unless greater effort is placed into altering the course of the disease, this number is expected to rise to close to 30 million new cases by 2040.

More than 70% of the world's total new annual cases occur in Africa, Asia, and Central and South America. These regions account for more than 60% of the world's cancer deaths. Yet treatment for cancer is not widely available in these regions. Health systems are often not equipped to deal with detection and treatment of cancers. Prevention and early detection programmes are often weak or non-existent.

This situation is exacerbated by the high cost of treatment and, in particular, the high cost of newer cancer medication.

Cancer medication pricing has increasingly become a global issue creating access challenges in low-and middle-income countries. Death rates from cancer in wealthy countries are declining slightly because of early diagnosis and the availability of treatment.

But this isn't the case in low- and middle-income countries. For example, over 80% of children diagnosed with cancer in high-income countries will be cured. In low and middle-income countries the rate is as low as 10%.

Massive disparities

Only 5% of global resources for cancer are spent in the developing world. Yet these countries account for almost 80% of disability-adjusted years of life lost to cancer globally. And developing countries, governments and individuals struggle to pay for products that are priced at several times the level of their per capita GDP. Buyers are at the mercy of a single provider, often the patent holder of the product, particularly where the product has no competitors.

In 2018 the World Health Organisation found that pricing of cancer drugs was disproportionately higher than other types of pharmaceuticals and therapies.

Nor is it just a question of price. Efficacy comes into the picture too. In 2017, estimated global expenditure on medicines for cancer and related supportive care amounted to US$ 133 billion. Despite these huge costs, a systematic evaluation of 68 cancer medicines approved by the European Medicines Agency in 2009-2013 showed that only 35% had established evidence of prolonged survival at the time of approval. Similarly, only 10% of the 68 medicines had evidence of improvement in the quality of life at the time of approval.

In addition, some medicines may present higher risk of toxicities to patients, with evidence of high rates of deaths related to treatment (toxic deaths) and high chances of patients discontinuing treatment due to intolerance.

Some answers

We often hear that efforts to expand cancer care aren't affordable and will divert resources from higher priorities. A similar view was once held about HIV/AIDS. Yet we have seen remarkable success expanding access to services. Many lessons can be learnt from this experience. For example, generic drug competition in the HIV market has been essential in bringing the price of antiretroviral medicines down dramatically.

Developing countries should be encouraging the use of generic and biosimilar cancer medicines with a view to enhancing competition. This will certainly drive down cancer drug prices. For example, in Norway, an infliximab biosimilar was discounted by nearly 70% and now represents more than 50% of drug sales. Similarly, in India and Peru, a rituximab biosimilar was introduced at a 50% lower price compared to the originator, illustrating the value they bring into oncology care.

In addition, governments must ensure that the application of patent law and rights for market exclusivity are not over compensating innovators and becoming barriers to access. Such activism has been found resonance in many countries as has been the case in South Africa.

These approaches are important to create platforms for engagement and the political momentum to strengthen health care for cancer patients at national level and take action globally to provide guidance for treatment and care, share knowledge about treatment cost and provide a legal framework to ensure treatment is available.

The cost of new drug development as an explanation for the high prices of new medicines is doubtful. Yet when it comes to health care and certainly in the case of potentially fatal diseases such as cancer, people are willing to bear a heavy burden even if the health benefits in reality turn out to be limited.

What's important is that biomedical and technological advancements don't introduce greater disparities and inequities when it comes to access to care and outcomes. The watch word must be affordability, not profitability.

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