Transcript Document

Global Comparator Report on
Funding and Access to Oncology Drugs
with special reference to South Africa
Dr Nils Wilking
Karolinska Institutet, Stockholm, Sweden
October 6, 2007.
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.
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.
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
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.
Disease All sites but non-melanoma skin Sex Female age [0-85+]
Incidence
400
Age Standardised Rate (World)
350
300
Country
Canada
250
Czech republic
Denmark
Finland
200
New Zealand
Norway
Sweden
150
100
50
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
0
Year
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.
Disease All sites but non-melanoma skin Sex Male age [0-85+]
Incidence
400
Age Standardised Rate (World)
350
300
Country
Canada
250
Czech republic
Denmark
Finland
200
New Zealand
Norway
Sweden
150
100
50
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
0
Year
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.
Disease All cancers Sex Female age [0-85+]
Mortality
300
Age Standardised Rate (World)
250
Country
200
Norway
Poland
Portugal
Spain
Sweden
150
Switzerland
United Kingdom
United States of America
100
50
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
0
Year
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.
Disease All cancers Sex Male age [0-85+]
Mortality
300
Age Standardised Rate (World)
250
Country
200
Norway
Poland
Portugal
Spain
Sweden
150
Switzerland
United Kingdom
United States of America
100
50
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
0
Year
Incidence of breast cancer in Canada, Czech Republic, Denmark,
Finland, New Zealand, Norway and Sweden given as agestandardized rate.
Disease Breast Sex (Alla)
Incidence
100
Age Standardised Rate (World)
90
80
70
Country
Canada
60
Czech republic
Denmark
50
Finland
New Zealand
Norway
40
Sweden
30
20
10
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
0
Year
Mortality of breast cancer in Norway, Poland, Portugal, Spain,
Sweden, Switzerland, United Kingdom and the United States of
America given as age-standardized rate.
Disease Breast Sex (Alla) DataCategory (Alla)
Mortality
35
Age Standardised Rate (World)
30
Country
25
Norway
Poland
20
Portugal
Spain
Sweden
Switzerland
United Kingdom
15
United States of America
10
5
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
0
Year
Causes of Death and Disease Burden
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)
Czech Republic/
Hungary/Poland
South Africa
E-13
Population (million)
44.8
All disease groups
Total
DALY/
Total
DALY/
Total
DALY/
DALYs
1000
%
DALYs
1000
%
DALYs
1000
%
20,560,460
459.4
100
9,085,571
154.8 100.0 45,027,283
123.2 100.0
HIV/AIDS
58.7
365.4
10,421,670
232.8
50.7
8,536
0.1
0.1
154,758
0.4
0.3
Injuries
1,744,778
39.0
8.5
1,047,070
17.8
11.5
3,487,994
9.5
7.7
Mental disease
1,394,840
31.2
6.8
1,970,862
33.6
21.7
12,122,002
33.2
26.9
Cardiovascular disease
958,267
21.4
4.7
1,987,288
33.9
21.9
7,447,825
20.4
16.5
Diarrhoea
478,577
10.7
2.3
15,436
0.3
0.2
96,781
0.3
0.2
Cancer
459,145
10.3
2.2
1,483,130
25.3
16.3
7,507,887
20.5
16.7
Tuberculosis
445,863
10.0
2.2
24,812
0.4
0.3
35,504
0.1
0.1
Nutritional deficiencies
443,058
9.9
2.2
54,666
0.9
0.6
264,523
0.7
0.6
Respiratory disease
419,464
9.4
2.0
286,855
4.9
3.2
2,984,745
8.2
6.6
Cancer in developing countries
The 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
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
506,111
70
Cancer
Cancer is rapidly increasing, but is neglected, compared to infectious diseases
These diseases interact, increasing further the burden of disease
Crude Rates by Regions Adopted from Dr Ian Magrath
More
affluent
regions
have
higher
actual
incidence
and
mortality
rates and
lower
mortality:
incidence
ratios
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
The Global Pattern of Cancer; Contrasts
Males
INCIDENCE
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
Less and More Developed Crude Incidence
versus Cases Adopted from Dr Ian Magrath
3500
500
3000
400
2500
300
2000
200
1500
1000
100
0
500
0
Males
Less Developed
Females
Males
Less Developed
More Developed
Per 100,000 per annum
Females
More Developed
Thousands per annum
2002
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, >50% 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
Cancer Registration;
From CI on V Continents I-VIII
Adopted from Dr Ian Magrath
4%
6%
Fraction of
World
Population
10%
14%
47%
Africa
Latin America
N America
Asia
Europe
Oceania
14%
9%
5%
60%
11%
1%
19%
Number of registries does not accurately reflect population coverage
(e.g., African registries cover approx 7 million of the 888 million people
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
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
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
Japan
5 013
19 750
157
155
6.7 (%)
9.3 (%)
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
Total cancer drug sales
25000000
20000000
2003-2004
15000000
2000-2002
1995-1999
<1995
10000000
5000000
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Total cancer drug sales (€000s) in all 25 countries. 1995-2005 by year
of first world wide launch. Source IMS Health, IMS MIDAS Quantum
Limitations in Resources: Anti-Cancer Drugs
Anti-Cancer Drug Sales
Cancer
16%
61%
5%
18%
5%
19%
18%
61%
USA
Europe
Japan
Rest of World
Approval of cancer drugs
No of molecules approved 1995-2005 Average years from first launch of drug (worldwide) to sale
on country market
in the specific country
Including drugs with sale before Q2 2006 only
South Africa
Czech Republic
Hungary
Poland
United Kingdom
E-13 countries
15
19
20
24
23
23
2.1
2.1
2.3
2.4
1.0
1.4
*Drugs without sale before Q2 2006 were assumed to have sale in this quarter in the calculation of time lag
Including all drugs*
6.3
3.0
3.4
3.2
1.8
2.1
Limitations in Resources for Radiotherapy
Adopted 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
Inequities between countries in the
uptake and use of these drugs
South Africa
Cze ch Re public/Hungary/Poland
45000
450000
40000
400000
35000
350000
30000
300000
25000
250000
20000
200000
15000
150000
10000
100000
5000
50000
0
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
1995
1996
1997
1998
1999
Unite d Kingdom
2000
2001
2002
2003
2004
2005
E-13
900000
8000000
2003-2004
800000
2000-2002
7000000
1995-1999
700000
<1995
6000000
600000
5000000
500000
4000000
400000
3000000
300000
2000000
200000
1000000
100000
0
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
0
All countries
SA Insured pop.
South Africa
Poland
New Zealand
Czech Republic
United Kingdom
Hungary
Australia
Norway
Canada
Netherlands
Denmark
Italy
Spain
Sweden
Germany
Finland
Belgium
Austria
Switzerland
Japan
France
United States
PPP-adjusted per capita cancer drug sales (€)
in 22 of the study countries in 2005.
Distributed on drugs of different “vintage”
40
35
30
25
2003-2004
20
2000-2002
1995-1999
15
<1995
10
5
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
25
20
2003-2004
15
2000-2002
1995-1999
<1995
10
5
0
South Africa SA Insured
pop.
Poland
United
Kingdom
Czech
Republic
Hungary
E-13
Gemcitabine uptake in Czech Republic, E13, Hungary, Poland,
South Africa insured pop., South Africa total pop. and the UK
Molecule GEMCITABINE
Sales
25 000
Sum EUR per Population (100 000)
20 000
Country
Czech republic
15 000
E13
Hungary
Poland
South Africa Ins.
South Africa Tot.
United Kingdom
10 000
5 000
Y01 Q1
Y01 Q2
Y01 Q3
Y01 Q4
Y02 Q1
Y02 Q2
Y02 Q3
Y02 Q4
Y03 Q1
Y03 Q2
Y03 Q3
Y03 Q4
Y04 Q1
Y04 Q2
Y04 Q3
Y04 Q4
Y05 Q1
Y05 Q2
Y05 Q3
Y05 Q4
Y06 Q1
Y06 Q2
Y06 Q3
Y06 Q4
Y07 Q1
Y07 Q2
Y07 Q3
Y07 Q4
Y08 Q1
Y08 Q2
Y08 Q3
Y08 Q4
Y09 Q1
Y09 Q2
Y09 Q3
Y09 Q4
Y10 Q1
Y10 Q2
Y10 Q3
Y10 Q4
Y11 Q1
Y11 Q2
Y11 Q3
0
YearQuarter
Imatinib uptake in Czech Republic, E13, Hungary, Poland, South
Africa insured pop., South Africa total pop. and the UK
Molecule IMATINIB
Sales
60 000
Sum EUR per Population (100 000)
50 000
Country
40 000
Czech republic
E13
Hungary
Poland
30 000
South Africa Ins.
South Africa Tot.
20 000
United Kingdom
10 000
0
Y01
Q1
Y01
Q2
Y01
Q3
Y01
Q4
Y02
Q1
Y02
Q2
Y02
Q3
Y02
Q4
Y03
Q1
Y03
Q2
Y03
Q3
YearQuarter
Y03
Q4
Y04
Q1
Y04
Q2
Y04
Q3
Y04
Q4
Y05
Q1
Y05
Q2
Y05
Q3
Rituximab uptake in Czech Republic, E13, Hungary, Poland, South
Africa insured pop., South Africa total pop. and the UK
Molecule RITUXIMAB
Sales
40 000
Sum EUR per Population (100 000)
35 000
30 000
Country
Czech republic
25 000
E13
Hungary
Poland
20 000
South Africa Ins.
South Africa Tot.
United Kingdom
15 000
10 000
5 000
YearQuarter
Y09 Q1
Y08 Q4
Y08 Q3
Y08 Q2
Y08 Q1
Y07 Q4
Y07 Q3
Y07 Q2
Y07 Q1
Y06 Q4
Y06 Q3
Y06 Q2
Y06 Q1
Y05 Q4
Y05 Q3
Y05 Q2
Y05 Q1
Y04 Q4
Y04 Q3
Y04 Q2
Y04 Q1
Y03 Q4
Y03 Q3
Y03 Q2
Y03 Q1
Y02 Q4
Y02 Q3
Y02 Q2
Y02 Q1
Y01 Q4
Y01 Q3
Y01 Q2
Y01 Q1
0
Trastuzumab uptake in Czech Republic, E13, Hungary, Poland,
South Africa insured pop., South Africa total pop. and the UK
Molecule TRASTUZUMAB
Sales
40 000
Sum EUR per Population (100 000)
35 000
30 000
Country
Czech republic
25 000
E13
Hungary
Poland
20 000
South Africa Ins.
South Africa Tot.
15 000
United Kingdom
10 000
5 000
0
Y01 Y01 Y01 Y01 Y02 Y02 Y02 Y02 Y03 Y03 Y03 Y03 Y04 Y04 Y04 Y04 Y05 Y05 Y05 Y05 Y06 Y06 Y06 Y06 Y07 Y07 Y07 Y07 Y08
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
YearQuarter
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.
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…”
Contribution of the increase in cancer drug vintage to the decline in the age-adjusted
cancer mortality rate. Frank Lichtenberg; Columbia University, NY,NY.
1.05
actual
1.00
if no increase in drug vintage
0.95
0.90
0.89
0.85
0.84
0.80
1995
1996
1997
1998
1999
2000
2001
2002
2003
Increase in drug vintage accounts for 30% of the 1995-2003 decline in the age-adjusted
cancer mortality rate.
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
Final comments
• Patients should have equal
and early access to
innovative treatments
• Research on access of
therapy is an important part
of cancer research