Posts tagged ‘Glivec’

October 21, 2011

The Cost of Cancer

There has been much comment in the media over recent weeks about the cost of cancer in New Zealand. This has been driven by two recently published reports – a Ministry of Health report, ‘ The Price of Cancer’, which has put the cost of diagnosing and treating cancer at over $500 million each year. This figure is likely to increase by 20% by 2021. An article also appeared in the Lancet journal ‘Delivering affordable cancer care in high income countries’, which puts the worldwide cost of cancer from disability and premature death at US$895 billion.

These reports have raised some key questions. What are the drivers and solutions to the cost of cancer in New Zealand and how are we going to deliver high quality and equitable care?

There is no getting around it – cancer is expensive to treat and blood cancer is in the top three of the most ‘expensive cancers’ (behind breast cancer and colorectal cancer). Treatments for blood cancer are complex, and often long-term. Bone marrow transplants do not come cheaply, including transporting donor marrow across the world, and extensive chemotherapy is often needed for long periods of time.

Considering that cancer is New Zealand’s biggest killer, causing nearly 30 per cent of all deaths, it’s very important that a multi-faceted approach is taken when looking at cancer interventions and treatment. There is no quick fix solution to reducing the cost of cancer, but I believe it critical that as we consider solutions we should ensure they are patient-focused.

Rather than looking purely at the fiscal costs of cancer interventions and treatment, it is important that we also consider the huge costs to the patients and their families who receive a cancer diagnosis. Cancer takes an enormous toll on patients and families and this does lead to corresponding costs to the country. Aside from the physical and psychological effects of being ill or supporting a loved one through cancer treatment and physical side effects there are many associated psychosocial effects.

Many patients and their families have to cease work and relocate to other cities with very little notice, to receive the treatment they require. Often a partner or spouse will also need to quit their employment to support them, at times the family is split geographically to manage family and school care. This can often have huge practical and financial implications. Cancer puts great strain on families, and separation and stress may often result in the breakdown of family units. There are also longer term implications for patients who in some settings may face discrimination or difficulty in re-entering the workforce and are penalised heavily with future insurance needs.

There have been suggestions over the last few weeks, that New Zealand should be more selective about what treatments are offered to cancer patients, as some are not particularly effective and we shouldn’t be investing in ‘new technologies’.

While there is no denying it is very important to consider the effectiveness of treatments on offer, continued investment in cancer treatments is crucial. These treatments not only significantly improve survival; they reduce hospitalisations and the need for expensive supportive care, not to mention in many cases allowing the individual back to real life and participating in the workforce.

There are a number of less obvious costs to the country when people with cancer are not treated quickly and effectively. This seems to be forgotten when wringing our hands and crying poor as a country because new medicines are costly. One thing is certain we are in a new era of drug development, yes it is costly, but we are also getting smarter at not using the shotgun approach but instead treating smaller subsets of patients with targeted medicines which are not given to those we know won’t respond.

A really good example of this is Glivec (imatinib). We lobbied hard for the funding of this drug nine years ago. Glivec is used to treat chronic myeloid leukaemia (CML). Prior to Glivec being released, CML was a deadly disease for the majority of patients. With the advent of Glivec, CML has become a manageable chronic disease. When CML is detected early and treated well, patients can expect to live a long and good quality life, taking a pill on a daily basis. For around 90% of patients their disease will not progress. Put basically, this treatment has allowed patients to remain in the workforce and out of hospital, thus reducing the costs to taxpayers.

There are many steps that can be taken to improve processes and understanding and therefore provide some solutions to the increasing cost of cancer. I would suggest that this should start by putting patients at the centre of the solution. A simple example would be to start with clinical trial design. There needs to be a far greater focus on patient reported events, side effects, additional monitoring interventions, and greater reporting of the impact on quality of life, ability to return to work etc. These simple changes could be factored into drug assessments alongside their clinical efficacy and form part of regulators and payers decision-making. New Zealand is woefully lagging in the area of patient representation on key evaluation committees and in areas where they are directly affected – but their view is neither sought nor respected.

A patient-centred focus on wastage and compliance would also realise savings. It is perhaps the unique area that I would say, PHARMAC, industry, doctors, pharmacists and patients all align and each benefit from good adherence to treatment. We know many patients are not fully compliant with oral medicines once their disease appears to be under control. Not being compliant is costly (the drug has already been paid for and dispensed) the patient’s treatment is suboptimal, the company has in an interest in knowing their drugs are used properly for maximum benefit as do the doctors who are prescribing them.

It’s really important that patients are well-educated by health professionals about their cancer medications. Effective understanding results in medication being taken as prescribed, meaning that it will work effectively and reduce the need for additional treatment or hospitalisation.

Apart from the myriad of other areas to tackle with drug regulation and reimbursement I also see it to be very important that when looking at the cost of cancer we consider the need for investment in research in New Zealand. What causes particular cancers? We know that with blood cancers we are short on these answers, hence no prevention messaging. The more we can find out about these deadly diseases, the more we can do to prevent them, thus saving lives and reducing the need to invest further millions of dollars into treating them.

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June 14, 2011

PHARMAC not always a perfect model for specialised drug funding

Nearly nine years ago, New Zealand’s drug-buying agency PHARMAC, gave the all-clear to fund Glivec (also known as imatinib).

The funding of the drug has given much hope to Kiwis diagnosed with CML (chronic myeloid leukaemia), with most patients able to achieve remission. The course of this disease was markedly different 10 years ago when other medications were the standard treatment. At that time, most patients progressed to the advanced phase of the disease and a large number died as a result of CML.

At the time, Glivec was hailed globally as a new era in drug development, the first in a new era of targeted new medicines – and all these years later that has been borne out. Nearly all these New Zealandpatients treated with Glivec are still leading active and productive lives.

Whilst we at the Leukaemia & Blood Foundation are very, very pleased that there has recently been several drugs funded for haematology patients, the approval process for funding has – as is usual – been very much delayed, commonly over a number of years.

A lot of respected voices have been heard in the media recently applauding the PHARMAC model. We agree it is certainly true that the agency serves New Zealand very well with regards to funding generic drugs; and the supply of drugs for a mass market with an eye to containing costs. We do, however, note that there is a far less rosy picture for many patients who require access to high cost and highly specialised medicines. This applies to thousands of cancer patients and others with chronic diseases. We need a system that can factor in providing access to these types of medicines as well.

We readily acknowledge there is a finite budget, and careful evaluation, drug by drug, is necessary. What we are struggling with is the review system that is deficient and fraught with delays, often for up to years on end.

Whilst our organisation has no agenda to see PHARMAC dismantled, we do believe the model lets New Zealanders down in the area of these highly targeted specialised medicines. Patients are often not well served in getting timely access to drugs in the more specialised fields, such as the one in which we operate.

We also remain concerned with the complete lack of transparency in the current funding model. We know first-hand the challenges in extreme delays with access.  In the intervening period it’s very difficult to get information with regards to the status of a particular drug’s funding status. We also see decisions are often selectively evidence-based.

The treatment for patients our foundation supports, many of whom have life-threatening illnesses, is obviously extremely time-critical and most can’t afford such delays.  There is also sometimes a false economy at play, in the case of haematology patients often the lack of access to a pharmaceutical treatment can frequently lead to even higher costs of supportive care in a hospital setting, such as intensive transfusion regimes with platelets, red blood cells, immunoglobulins and other treatments.

PHARMAC will shortly announce the results of a review into the Exceptional Circumstances scheme which is also part of the equation, and very much so for smaller patient populations. Let’s hope that a sense of fairness and equity can be brought to bear, first indications from the consultation were that this was not the case.

Nine years on from PHARMAC’s funding of Glivec, we reflect on the effectiveness of its funding model for a small population. Glivec was called the silver bullet and, for those diagnosed with CML, it certainly has been. We’d love to see this success replicated throughout the system.