Patients around the world face stark inequalities in access to cancer treatment

Patients around the world face stark inequalities in access to cancer treatment, according to a report published in the cancer journal, Annals of Oncology.

The report's authors urge decision makers in every country to take action and ensure that everyone has equal access to new cancer drugs when they are needed, wherever they live.

The report by Dr Nils Wilking, clinical oncologist at the Karolinska Institute in Stockholm, Sweden, and Dr Bengt Jonsson, director of the Centre for Health Economics at the Stockholm School of Economics, updates and improves on an earlier report by the same authors published in 2005.

The new report covers 25 countries, including Australia, Canada, New Zealand, Japan, South Africa and the USA, as well as 19 European countries, with a total population of 984 million, and it looks at access to 67 innovative cancer drugs. It reveals that 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.

The authors report that uptake of new cancer drugs is "low and slow" in New Zealand, Poland, Czech Republic, South Africa and the UK.

Dr Jonsson said: "The greatest differences in uptake were noted for the new colorectal and lung cancer drugs: bevacizumab, cetuximab, erlotinib and pemetrexed." (Lung and colorectal cancer are among the world's top cancer killers for both men and women). The USA's uptake of bevacizumab for colorectal cancer was ten times the uptake of the European average. In Europe, Austria, France, Germany, Spain and Switzerland had uptake that was higher than the European average; Denmark, Hungry, Norway, Poland and Sweden had low uptake; and Italy and the UK had very low uptake. The uptake of cetuximab was highest in France and the USA and low in Finland, The Netherlands, Poland and Sweden. For lung cancer, uptake of erlotinib was ten times higher than the European average in the USA and three times higher in Germany. Uptake in Australia, the UK, Norway and Poland was low. For pemetrexed, France and the USA had a high uptake and Canada, Czech Republic, New Zealand, Poland and the UK had a low uptake.

Dr Wilking said: "Progress in medical treatments has meant that over half of the patients diagnosed with cancer will now be 'cured' or die from other causes. However, these benefits are only realised once the drugs get to the patients. Our report highlights that in many countries new drugs are not reaching patients quickly enough and that this is having an adverse impact on patient survival. Where you live can determine whether you receive the best available treatment or not. To some extent this is determined by economic factors, but much of the variation between countries remains unexplained.

"In the US we have found that the survival of cancer patients is significantly related to the introduction of new oncology drugs. From a European perspective, we have found differences in access reflected in patient outcome in the five major western European countries: France, Germany, Italy, Spain and the UK."

Of these five European countries, France had the highest five-year survival rate for all cancers (apart from non-melanoma skin cancer): 71% for women and 53% for men. Spain had five-year survival rates of 64% and 50% respectively, in Germany it was 63% and 53%, in Italy 63% and 48%, and the UK had the lowest at 53% and 43% respectively. The report also shows that in France, Spain, Germany and Italy 51-52% of cancer patients were treated with drugs launched after 1985, but only 40% of patients in the UK had access to these drugs.

Dr Jonsson said: "Around one sixth of the differences between these five countries in five-year cancer survival is due to differences in the uptake of new drugs in each country."

Two other analyses in the report also related access to new cancer drugs with improved patient survival. Dr Wilking said: "Nearly half of the observed improvement in the two-year cancer survival rate between 1992 and 2000 at 50 USA cancer centres could be attributed to the use of newer cancer drugs. In 20 countries, including the USA and Europe, between 1995 and 2003, nearly a third of the reduction in cancer deaths could be accounted for by the use of newer drugs."

The authors called for action to end the inequalities. "It is our hope that this report will inspire policy makers and decision makers to take action to address these imbalances so that access to new innovative cancer drugs does not become dependent on the patient's country of residence," they said.

They pointed out that although cancer was second or third in terms of disease burden in most countries, the share of health care expenditure allocated to it was significantly lower than the share of the burden of the disease.

Dr Jonsson said: "Cancer accounts for about 5-6% of all health care expenditure and cancer drugs account for between 10-20% of this expenditure and just 5% of all drug costs. But cancer research continues to grow, with many new drugs and treatments expected to be introduced in the coming years. Countries need to address urgently how they are going to accommodate newer drugs into health care systems and pay for them."

Economic evaluation of new drugs and their cost effectiveness were becoming increasingly important, the authors said, with Europe and the UK in particular playing a leading role in the production of health technology assessments. In the UK these are produced by the National Institute for Health and Clinical Excellence (NICE). "It was the explicit objective at the establishment of NICE to avoid any significant delays to bringing innovations to market in the UK. There is yet no evidence that this objective is met," they report.

The report also highlights an imbalance in public investments in cancer research between Europe and the USA. Dr Jonsson said: "Not only is the magnitude of public research at a different level in the United States, it is also directed to clinical research to a greater extent. There is a need for a significant increase in the public research for cancer in Europe, particularly devoted to clinical research."

The authors make a series of recommendations for ensuring that patients can have equal and rapid access to new cancer drugs. They include:

• Reducing the review time for the marketing authorisation of new cancer drugs;
• Ensuring that once authorisation is obtained, the drug is available at national level without further delays due to price and reimbursement negotiations;
• Ensuring that any economic evaluation or health technology assessment is done quickly to facilitate, and not delay, patient access;
• Ensuring that appropriate and adequate funding for new, innovative cancer drugs is available in the health care system and hospital budgets, preferably on a proactive basis and not reactive basis i.e. by planning ahead.

Dr Jonsson concluded: "We believe that the inequalities between countries in patients' access to cancer drugs cannot persist. Cancer patients will not accept that a standard of care available in one country is not available in other countries. Research on patient access to new treatment is a new and important part of translational cancer research."

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