Cancer drugs: value is about more than cost

When assessing the true value of cancer drugs, collaboration with key stakeholders, reform of the development process and reimbursement system, and a true understanding of what is important to the patient must all be taken into account.

As the cost of cancer medicines dominates value discussions, other aspects of value that matter to patients, such as the impact of treatments on the length and quality of life, are at risk of being ignored in decisions about treatment availability. If this bias continues, it will mean that doctors and patients have fewer therapies to choose from.

Cancer innovation is a stepped process, with one step building on another to bring continuous improvements in care, which we like to call 'continuous innovation'. For example, a therapy introduced today may not show its real potential until it has been studied further in scientific trials and clinical practice. If we break this chain, we eliminate the possibility – and potential.

The research, development and commercialisation process is far from perfect. In fact, it is badly in need of repair. But there is no quick fix. To move forward we need:

• Collaboration and understanding among key stakeholders – industry, providers, policymakers, payers and patient advocates

• Change – in the way we determine and reward value, develop new treatments, and learn from our successes and failures

• Patient-centeredness – patients' needs, experiences and voices count.

Common foe

Cancer is the enemy. In 2012 alone, there were 14.1 million cancer cases and 8.2 million deaths globally.i Within two decades, cancer rates may almost double to approximately 22 million cases a year.ii

On the other hand, advances in cancer treatments are allowing patients to lead longer, healthier lives. According to Pharmaceutical Research and Manufacturers of America (PhRMA), which represents leading research-based pharmaceutical companies in the US, the chances that a cancer patient will live five years or more increased by 39 per cent across select cancers between 1975 and 2006.iii The five-year survival has increased 50 per cent for prostate cancer and 54 per cent for lung cancer since 1975 in the USiv. And, according to the Leukaemia and Lymphoma Society, the overall five-year relative survival rate for leukaemia has more than quadrupled since 1960 in the US.v

Approximately 83 per cent of survival gains in cancer are attributable to new treatments, including medicines.vi These treatments are also delivering enormous value to patients and society.vii

But, before we can make educated decisions about what constitutes value, we need to take into account some differences, namely:

• Not all cancers are the same; there are more than 200 different kinds of cancer.

• Not all treatments are the same; they are increasingly tailored to specific tumours and patients, and some are based on histology and gene expression.

• Not all patients are the same; cancer stage and prognosis, age, genetic makeup, concomitant disease, priorities, preferences and support systems are a few of the variables.

"New drug therapies demonstrate cost effectiveness by reducing use of other medical resources such as hospitalisations, doctor visits and rehabilitative care"

Moreover, the biggest untold story is that cancer medicines make up the smallest and most stable portion of overall cancer care expenditure. In the EU, drug expenditurex accounted for 27 per cent of cancer-related healthcare costs in 2009.ix In the US, drug expenditure amounts to 20 per cent of cancer care expenditure and less than 1 per cent of overall US healthcare expenditure. In addition, new drug therapies demonstrate cost effectiveness by reducing use of other medical resources such as hospitalisations, doctor visits and rehabilitative care.xii

Change for the better

In addition to collaboration and understanding, the problem needs to be considered holistically and reforms adopted. Here are some ideas under discussion with stakeholders:

• Transform the cancer clinical research system and regulation

There must be changes in procedures to permit: faster trial accrual; greater use of adaptive trials; conditional approvals; better electronic sharing of real-world patient data; and, in some cases, consideration of alternative trial endpoints as the basis for product registration.

• Alleviate the bias against medicines in the payment system

Insurance design favours reimbursement of hospital stays and other healthcare expenses compared with the cost of oncology drugs. This bias obscures the cost of other components of care, while creating the impression that medicines are a disproportionate cause of high cancer treatment expenses.

• Reform the reimbursement system

The current reimbursement system effectively means that high initial prices are the best or only option to recoup investment in a product. Introducing pricing flexibility into the reimbursement system and enabling drug prices to rise and fall in response to new information about their demonstrated value would be a positive step.

"Patients need to understand their options and be an active part of treatment decisions"

Patient-centeredness is key

Above all, the patient must be at the centre of our discussions. Patients need to understand their options and be an active part of treatment decisions because, often, value is subjective. A patient with advanced disease, for which there are few or no treatment options, may appreciate the extra months spent with family and friends that a new treatment may bring. For another, side effects and quality of life may contribute more to the decision.

The bottom line is that cancer medicines can deliver good clinical and economic value for patients, healthcare systems, economies, and societies. Our aim should be to ensure that oncologists and patients have a strong armament of therapies from which to choose.

References

i International Agency for Research on Cancer (IARC). Globocan 2012: Estimated Cancer Incidence, Mortality and Prevalence. Available at http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx. Accessed September 1, 2014.

ii International Agency for Research on Cancer (IARC). World Cancer Report 2014. Edited by Bernard W Stewart and Christopher P Wild

iii PhRMA Cancer Chart Pack. Cancer Medicines: Value in Context. Spring 2014. Page 5. Available at http://www.phrma.org/sites/default/files/pdf/cancer-chart-pack-5-22-14.pdf. Accessed August 13, 2014.

iv PhRMA Five Facts About The Value of Innovative Medicine. Available at http://www.phrma.org/catalyst/five-facts-about-the-value-of-innovative-cancer-medicines#ref2. Accessed August 13, 2014.

v Leukaemia and Lymphoma Society. Facts; Spring 2014. Available at https://www.lls.org/content/nationalcontent/resourcecenter/freeeducationmaterials/generalcancer/pdf/facts.pdf. Accessed August 13, 2014.

vi PhRMA Cancer Chart Pack. Cancer Medicines: Value in Context. Spring 2014. Available at http://www.phrma.org/sites/default/files/pdf/cancer-chart-pack-5-22-14.pdf. Accessed August 13, 2014.

vii Yin W et al. Value of Survival Gains in Chronic Myeloid Leukaemia. Am J Manag Care Nov 2012 (11 Suppl): S257-65.

viii Cancer Research UK. How many different types of cancer are there? Available at http://www.cancerresearchuk.org/cancer-help/about-cancer/cancer-questions/how-many-different-types-of-cancer-are-there. Accessed September 2, 2014.

ix Luengo-Fernandez R et al. Economic burden of cancer across the European Union: a population-based cost analysis. Lancet Oncol 2013; 14: 1165–74.

x K Fitch et al. "Benefit Designs for High Cost Medical Conditions" Milliman Research Report. April 22, 2011. Figure 13, Page 11

xi PhRMA. Cancer medicines: Value in Context. Cancer Chart Pack. Spring 2014.

xii C Stuart, J A et al. Assessing the Impact of Drug Use on Hospital Costs, Health Services Research 44, no. 1 (2009): 128–144. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669633/. Accessed August 22, 2014.

About the author:

Sue Mahony PhD is president of Lilly Oncology, senior vice president at Eli Lilly and a member of the company's executive committee. She holds a BSc and a PhD from Aston University and a master's degree in business administration from the London School of Business.

Mahony joined Lilly in 2000 after more than a decade in sales and marketing roles in the UK and Europe in oncology/haematology and cardiovascular medicine for Schering-Plough, Amgen and Bristol-Myers Squibb. Since joining Lilly, Mahony has held roles in global marketing, product development, Six Sigma and general management. She was also a global brand development leader for duloxetine (Cymbalta) and fluoxetine (Prozac).

She is a member of the Patient Access to Cancer care Excellence (PACE) Global Council, which brings together patient advocacy, medical, policy, scientific and healthcare industry leaders. PACE is a Lilly Oncology initiative that exists to encourage public policies and healthcare decisions that speed the development of new medicines, promote rapid learning from patient experiences, and ensure that cancer treatment and care respond to the needs and qualities of individual patients.

Have your say: To what extent are reimbursement reforms likely?