New cancer treatments offer patients improved outcomes – but they are causing increasing headaches for the health budget, writes PRISCILLA LYNCH
LAST WEEK, the political rows over the reimbursement of skin cancer drug ipilimumab for public patients highlighted the question, can we afford to provide innovative cancer treatment?
In Ireland, there are an average of 30,000 new cases of cancer a year, a rise of 50 per cent since the mid-1990s, while there is a projected growth of more than 100 per cent in the number of cancer cases over the coming decade.
In turn, the costs of cancer treatment to the health service have increased substantially over the past decade and will rise further in the coming years with an ageing population and advances in treatment.
There have been many exciting new developments in targeted therapies and biologic treatments for cancer patients in recent years, but these innovative treatments are not cheap.
The EU recently hosted a special workshop that explored the issue of whether society can afford innovative cancer treatments.
The development period of new medicines can take up to 12 years, with investments of more than €1 billion needed to successfully bring just one new drug to market. Consequently, new innovation comes at a price, which in turn leads to the question of whether society is willing to pay for modern cancer treatment.
A debate is now needed, as the cost of cancer treatment has become a major issue across Europe, a number of cancer experts told the EU workshop.
In the context of the continuing reduction in the State’s health budget, many are beginning to question if we can afford to spend so much money on cancer treatment when all other areas of the health service are being asked to make painful cuts.
The furore over the reimbursement of ipilimumab for public patients is a classic example of policymakers being asked if the potential treatment outcome is worth the high financial cost.
Clinical trials on ipilimumab have shown good results regarding prolonged survival and increased disease control for advanced melanoma. The drug adds on average 3.7 months to the life of a patient treated with it, but for one in 10 it is a cure.
However, it can have serious side effects, and the current treatment cost of approximately €85,000 per patient could equate to between €4.8 million and €7.4 million this year, increasing to between €5.3 million and €8.2 million in 2016.
The National Centre for Pharmacoeconomics (NCPE) carries out health technology assessments (HTAs) to determine if a new drug or therapy is cost-effective. It then makes its recommendations available to the HSE.
It has given negative assessments to a number of expensive new cancer treatments in recent years, including ipilimumab and cabazitaxel, a new prostate cancer drug.
In addition, following an initial rapid review, the NCPE decided that Teysuno, a drug for advanced gastric cancer, should not receive a full pharmacoeconomic evaluation.
However, in the case of cancer drugs, the National Cancer Control Programme (NCCP) can carry out its own further assessments and has on occasion come to a different conclusion to the NCPE.
Following the public outcry last summer over the decision of the NCPE not to recommend the public reimbursement of the Oncotype DX test for breast cancer – the use of which can spare up to 30 per cent of patients who would otherwise have received chemotherapy treatment and also provides extra information on the likelihood of cancer recurrence – the NCCP stepped in.
It made a positive assessment of the test and, following negotiations with its manufacturer, announced last October that it would be made available to suitable public breast cancer patients after all.
In the case of ipilimumab, the NCCP recommended that it should be reimbursed, but ultimately the decision on whether to fund new treatments lies with the HSE centrally, and recently it has been slow to give the green light to funding for expensive new therapies that have received positive HTAs.
However, on Friday, the Department of Health announced that ipilimumab would be made available to patients. The HSE and the National Cancer Control Programme (NCCP) said in a statement it had reached agreement with the drug’s manufacturers, Bristol-Myers Squibb, following negotiations going back to November. It is anticipated that 60 Irish patients will be eligible for the treatment this year.
Currently, cancer medicines are funded by individual hospitals or through community schemes, most commonly the High Tech Drugs scheme. This is set to change later this year when the NCCP will begin the process of centralising the cancer drugs budget, which it says will be demand-led, with the primary aim of ensuring the best, validated treatment for cancer patients equally across the country.
However, some cancer specialists are worried the move will limit their individual access to the latest innovative drugs and new combination treatments.
Leading cancer researcher and campaigner Prof John Crown, consultant medical oncologist in St Vincent’s University Hospital Dublin, and a member of the Seanad, has absolutely no hesitation in saying “yes we can and must” invest in innovative cancer treatment.
He says the cost of cancer treatment was tiny compared to the billions of euro that had been used to bail out the banks and service our international debt repayments.
“The reality is if they let us be clever in the way we use cancer drugs, they wouldn’t be that terribly expensive. We can afford them,” he says.
“The total cost of cancer drugs in this country as a percentage of the total amount spent on pharmaceuticals is quite small.”
He added: “Cancer is the leading cause of death in our country. Join the dots.”
Melanoma: the facts
The timing of the ipilimumab row was noteworthy given that May is melanoma awareness month.
Skin cancer is the most common cancer in Ireland and melanoma is the more serious, rarer type of skin cancer, while non-melanoma is the more common, less life-threatening group.
There are an average of 719 melanoma cases a year in the Republic, 392 in women and 327 in men, and it was the seventh most common cancer in Ireland between 1995-2007.
The latest advances in melanoma treatment, including the development of ipilimumab, were discussed at the inaugural Melanoma Forum last November.
Speaking at the Forum, Dr Linda Sharp, epidemiologist with the National Cancer Registry of Ireland, said the incidence of melanoma in the Republic has risen faster than most other types of cancer in the last 15 years.
Invasive (spreading) melanoma rose by 79 per cent for women and 134 per cent for men between 1994 and 2009, while in situ (confined) melanoma cases rose by 154 per cent for women and 341 per cent for men within the same time period.
Disturbingly, even after adjusting for socio-economic factors, the incidence of melanoma is 15 per cent (men) to 18 per cent (women), higher in the Republic than in Northern Ireland, she noted.
Survival rates are also much lower in the Republic compared to Northern Ireland, though overall the Republic’s survival rates are about the European average, Sharp said.
There are about 100 deaths a year on average from melanoma in the Republic. Survival rates are currently significantly higher in women than men (88 per cent for women and 79 per cent for men), she reported, though these rates have significantly improved for both sexes since 1995.
Looking at the risk factors and causes of melanoma, Dr Patrick Ormond, consultant dermatologist at St James’s Hospital, Dublin, confirmed that skin cancer is a disease that disproportionally affects the wealthy as they tend to go on more sun holidays.
However, he told the forum the effect of cheap flights on the incidence of skin cancer will be an issue in Ireland in the coming 10-15 years.
Ormond listed pale skin, red hair, tendency to freckle, a large amount of moles, and having experienced severe sunburn as a child as the main individual risk factors.
Poor use of sun protection in Ireland, particularly among young adults and men, leaves them more at risk of melanoma.
If you are concerned about a new or existing mole or skin lesion, you should contact your GP or dermatologist
There is an average of
719
melanoma cases a year in the Republic;
392
in women and
327
in men
Invasive (spreading) melanoma rose by
79%
for women and by
134%
for men between 1994-2009