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Global Collaborative Healthcare - Fixing Cancer’s Global Disparities
Fixing Cancer’s Global Disparities
David H. Freedman
Date: June 20, 2014
Illustration by Jean François Podevin
Meeting with his first patient in his new position in a cancer treatment center in Singapore, oncologist Gilberto Lopes recommended a standard chemotherapy protocol—CAPOX and bevacizumab—considered reasonably effective against this patient’s metastatic colorectal cancer.
Lopes knew that patients deal with the prospects of battling the disease in many different ways. But he was surprised by this patient’s response: She flat-out refused the treatment as too expensive—even though the costs would be completely covered by funds sitting in her health care savings plan. “She just didn’t want so much money to go to extend her life,” recalls Lopes. “She wanted her family to inherit it.”
Lopes, who now heads the oncology center at Hospital do Coração in Brazil and is also on the faculties of Perdana University’s Graduate School of Medicine in Malaysia and the Johns Hopkins University School of Medicine, tells the story as a small illustration of the nuances and complexities that surround the care and costs of cancer—and how they can differ around the world.
All diseases pose challenges for both health care systems and patients, including questions of which patients pay for what care at what costs, with answers differing country to country. But the issues raised by cancer are especially thorny and important because of the disease’s prevalence, mortality rates and high average cost of treatment. What’s more, there are sharp inequities in access to care among different populations around the globe.
It is this last problem that is of special concern to Lopes, particularly with regard to the developing world, which has more than its share of cancer deaths and far less than its share of access to treatment. To address that situation, Lopes has thrown himself into researching and advocating for ways that governments, health care organizations, NGOs and even ordinary citizens can reduce the disparities, or at least lower the toll those disparities take on populations. And thanks to having practiced in different countries around the world, he has been able to conduct studies that are relevant not just to the most affluent nations, but to more vulnerable populations in parts of Asia, South America and elsewhere.
His goal: To get more and better cancer care to regions of the world that currently have few affordable treatment options. “There are ways to bring down the costs of effective cancer treatment so that most people have access to it,” says Lopes. “Right now, most cancer patients don’t.”
THE PROGRESS GAP
For virtually the entire history of the human race, the greatest disease threat to living a long life was infectious disease. In fully industrialized nations, where modern medicine largely tamed infectious disease more than a century ago, that threat long since shifted toward chronic, noncommunicable diseases (NCDs): cardiovascular disease, cancer, diabetes and Alzheimer’s, among others. In much of the developing world, in contrast, the focus until recently has remained on the ravages of deadly, still-untamed infectious diseases such as malaria, tuberculosis and AIDS. But now there’s growing recognition that NCDs have quietly taken over as the primary cause of death in the less industrialized world, too. It’s there where the biggest burden of NCDs lies today. With NCDs accounting for nearly two-thirds of deaths around the world, fully 80 percent of those deaths are in low- and middle-income nations.
Among all the NCDs in low-income countries, cancer is the leading killer, taking more lives there than all the major infectious diseases combined, points out Lopes. And cancer takes an enormous economic toll as well, he adds, costing the world about $1 trillion a year in lost productivity alone, not counting the even larger costs of treatment. “Cancer costs are almost 20 percent higher than heart disease costs worldwide,” he notes.
Significant progress has been made in the battle against cancer in highly industrialized countries. A few decades ago, about half of all cancer patients in the U.S. lived five years or longer. That number has climbed to about two-thirds in the U.S., and it’s only slightly lower in other highly industrialized countries. Among the advances that are behind this improvement: vaccines that help prevent the most common form of liver cancer and cervical cancer; lower smoking rates; screening for earlier detection of breast and colorectal cancer; and more effective treatments for several cancers, including breast and ovarian cancer and lymphoma. And researchers are continuing to push the boundaries of “personalized medicine” by applying new insights from genomic research to create therapies that effectively target the genetic mutations in individual patients and even in a patient’s specific tumors.
But these improvements have largely left behind the developing world, Lopes argues, mostly because the new approaches are too expensive. The United States spends $460 per year per patient on treatment and prevention costs, compared to about $US 8 in South America, $US 4 in China and 50 cents in India. A country’s GDP per capita turns out to be a fairly reliable predictor of how likely it is that a patient will be able to access needed treatment. In Southeast Asia, for example, only 15 percent of patients in low- and middle-income countries had access to a representative group of standard-of-care cancer treatments, while 55 percent of patients in higher-income Singapore had access to them. “The gaps are enormous,” says Lopes.
Lawrence Shulman, chief of staff and director of the Center for Global Medicine at Boston’s Dana-Farber Cancer Institute, echoes Lopes’ concerns. “Low- and middle-income countries account for around two-thirds of global deaths from cancer, and yet only 5 percent of the global resources expended on cancer are available to those countries,” he says.
Lopes notes that this lopsided picture is likely to only worsen, given that treatment advances are increasingly expensive. It costs thousands of dollars to fully analyze an individual’s genetics, or that of a tumor, and the personalized therapies that such analyses point to can easily run into the many tens of thousands of dollars. For example, advanced treatments, such as monoclonal antibodies and tyrosine kinase inhibitors, available in the U.S. and other industrialized countries can be as much as $10,000 for a single treatment—costs that are typically mostly covered for U.S. patients by health insurance. But patients elsewhere usually have to pay most of the costs of such leading-edge treatments out of pocket.
Through his research, Lopes has identified a number of potential strategies for bringing cancer treatment costs down in the developing world. To advocate for their implementation, he has co-authored papers in such journals as Nature Reviews Clinical Oncology, The Lancet Oncology and the Journal of Clinical Oncology. And he travels around both the industrialized and developing world to speak at conferences and meet with government policymakers, NGOs and pharmaceutical industry executives. Among the measures for which Lopes advocates:
Using biomarkers as screening tools. Biomarkers can better determine which patients are more likely to benefit from a particular clinical trial, and that’s true in trials whether they take place in developing or industrialized nations. Studies have also shown that testing for a single genetic biomarker can decrease breast cancer clinical trial costs by nearly one-third while increasing the effectiveness of treatment by 50 percent, he adds, and enlisting biomarkers in lung cancer can quadruple success rates while dropping trial costs by more than one-quarter.
Making more generics available. Treatment costs drop by up to 80 percent when a generic version of a drug becomes available as an alternative to a very expensive drug such as bevacizumab and ipilimumab. Though pharmaceutical companies often resist licensing compounds to generics manufacturers, some countries have had success with “compulsory licensing” of generics—that is, issuing permission to generics manufacturers in the country to produce a generic drug without the permission of the pharmaceutical that owns the patent, though requiring the manufacturer to pay the pharmaceutical company for the privilege. International law actually provides for that approach, as long it’s clearly in the public interest, and Thailand has successfully done so with cancer drugs, saving more than $140 million over five years.
Unfortunately, there is a perceived problem with the quality of many generics, with surveys indicating that up to half of physicians have doubts about them. Policymakers, generics makers and the health care community all have to address both real and perceived questions about generics, asserts Lopes. In addition, pharmaceutical companies have been known to respond to compulsory licensing in a country by reducing planned investments there. A related, less problematic solution may be developing “biosimilar” drugs that are different enough to not be covered by patents, Lopes says, but may be as safe and effective. Such drugs, however, are more difficult than generics to develop.
Price controls. Developing countries can negotiate with or require pharmaceutical companies to sell expensive but much-needed drugs at lower costs in those countries than they do in more affluent regions. Lopes points out that such policies are, perhaps surprisingly, not always entirely unwelcome to pharmaceutical companies, because the policies can allow these companies to sell a great deal of modest-profit product in a country in which it otherwise would have sold very little product at all while maintaining higher profit margins in affluent countries. The problem, rather, is that some affluent countries are predictably unhappy with having to pay much more than other countries do for the same product and may try to demand that companies sell to them at the same low price, which undercuts the entire scheme.
Shulman argues that making some of the most needed, effective and moderate-cost cancer drugs available to everyone who needs them should be regarded as a basic global humanitarian goal, akin to the way in which HIV treatment has been made widely available throughout the world over the past decade. “I think it can be argued that when a person is dying from something we can readily cure, that’s a breach of human rights,” he says. He adds that access to these drugs can be raised and costs lowered by creating ways to have them ordered and administered by trained personnel without having to involve an oncologist, given that there aren’t nearly enough oncologists to meet the needs of developing nations.
Programs that support wider access. Philanthropy, NGOs, entrepreneurs, governments and the investment community can team up in various ways to subsidize or finance the costs involved in making needed cancer treatments available to more of the population, says Lopes. One strategy: offering prizes for innovative approaches that increase access to treatment. There may eventually be significant funding to back such prizes: the Bill & Melinda Gates Foundation already sponsors a $250,000 vaccine innovation award, and a bill before the U.S. Congress would provide as much as $80 billion in prize money for pharmaceutical advancements, essentially replacing patents as a way of monetizing drug development.
Another approach to increasing access, notes Lopes, involves pricing schemes in which a pharmaceutical company isn’t paid for a drug given to a patient when the drug doesn’t prove safe and effective for that patient, thus lowering the costs and risks to the health care system of widely providing the drug. Such an agreement is in effect between Johnson & Johnson and the U.K.’s National Health Service for the multiple myeloma drug Velcade, for example.
Clinical trials, where they matter most. The high cost of treatment isn’t the only impediment to reducing cancer deaths in the developing world, notes Lopes. For one thing, he says, existing treatments may not be well suited to poorer countries, because the populations in those regions may suffer from cancers that are less common in other countries. Since less research tends to be conducted on diseases of these populations, there is often an absence of treatments that zero in on the specific forms of cancer encountered by them. Liver, stomach, neck and jaw cancers, for example, are more common in some regions of Asia and may not be addressed by as many treatment options as cancers more common in North America and Europe.
“Most clinical trials take place in affluent countries,” says Lopes, “but if we’re going to have better treatments for cancers that are common in developing countries, we need to do the clinical trials where those patients are.” There has been a trend to do more clinical trials outside of the U.S. and Europe, he adds, but there’s still a long way to go to achieve parity in such research. Lopes himself is working to establish a clinical trial on a traditional Chinese herbal medicine for heart disease that has been found to promote tumor shrinkage in animal models of breast cancer.
One bottom line, says Lopes, is that more money has to be thrown into the developing world’s fight against cancer. “We need to create a global fund that brings together the international finance community, the World Bank, the World Health Organization, other NGOs and many other stakeholders,” he says. “Right now three-quarters of nations don’t provide universal access to health care, and we need a way to make up the difference for cancer patients in those nations.”
Education can have a real impact as well, he adds, by explaining to children and young adults how they can greatly reduce their risks of various types of cancer through healthy behaviors—be they diet, exercise, preventive medical exams and more. To that end, he’s helped put together an animated short movie—currently in English, with Portuguese and Spanish versions in the works—and is planning a book. Lopes is also trying to start up an NGO focused on improving cancer education in low-income countries.
While global access to cancer prevention measures and effective treatment should be the ultimate goals, he notes, in the meantime it’s important to improve the quality of life of patients who do get cancer and their families, through patient-centered health care delivery approaches.
It won’t be any one effort or any one sector of society that solves the global disparity in cancer treatment, Lopes says. But every effort will make a difference. “There are things everyone can do through civil society to help control cancer both for themselves and the whole population,” he says. “We want to get more people involved.”
To view Gilberto Lopes' ANIMATED VIDEO for Johns Hopkins Singapore patients, about cancer prevention, visit http://vimeo.com/70430457
David H. Freedman is a contributing editor to the magazine.