Patient access to innovative cancer drugs in the UK pales in comparison with countries such as France and the US, a new report has shown. The stark national disparities in uptake are also reflected in cancer survival rates, the researchers say.

The UK features with New Zealand, Poland, the Czech Republic and South Africa among countries with a “low and slow” uptake of new cancer drugs, according to the report by Dr Nils Wilking, clinical oncologist at the Karolinska Institute in Stockholm, Sweden and Dr Bengt Jönsson, director of the Centre for Health Economics at the Stockholm School of Economics.

The global report, which was supported by an unrestricted educational grant from Roche Pharmaceuticals, is published in the latest issue of the journal Annals of Oncology. It updates an earlier report by the same authors that was published in 2005.

The researchers looked at access to 67 innovative cancer drugs in 25 countries including 19 in Europe. They found that Austria, France, Switzerland and the US were the leaders in the use of new cancer drugs, with France replacing Spain in the top four since the last report was published.

'Acute disparities' in colorectal and lung cancer drugs uptake

The most acute disparities were seen with the colorectal and lung cancer drugs bevacizumab (Avastin, Roche), cetuximab (Erbitux, Bristol-Myers Squibb/Merck KGaA), erlotnib (Tarceva, OSI Pharmaceuticals/Roche) and pemetrexed (Alimta), Eli Lilly. The US uptake of Avastin for colorectal cancer was 10 times the average in Europe. Uptake was above the European average in Austria, France, Germany, Spain and Switzerland, while it was “low” in Denmark, Hungary, Norway, Poland and Sweden, and “very low” in Italy and the UK.

France and the US showed the highest uptake of Erbitux, while low uptake was seen in Finland, the Netherlands, Poland and Sweden. Use of Tarceva for lung cancer was 10 times higher than the European average in the US and three times higher in Germany; uptake was low in Australia, the UK, Norway and Poland. With Alimta, the researchers saw high uptake in France and the US, and low uptake in Canada, the Czech Republic, New Zealand, Poland and the UK.

The introduction of new oncology drugs in the US correlated significantly with the survival of cancer patients, Wilking and Jönsson said. The report found that nearly half of the observed improvement in two-year cancer survival rates at 50 US oncology centres between 1992 and 2000 was attributable to the use of newer cancer drugs.

In Europe, differences in access to cancer drugs were reflected in patient outcomes for France, Germany, Italy, Spain and the UK. Of these five major western European countries, France had the highest five-year survival rate for all cancers (excluding non-melanoma skin cancer) – 71% for women and 53% for men – while the UK had the lowest (53% and 43% respectively). The report also showed that in France, Spain, Germany and Italy, 51-52% of cancer patients were treated with drugs launched after 1985, In the UK, only 40% of patients had access to these treatments.

Although in most countries cancer ranks second or third in terms of disease burden, its share of healthcare expenditure is significantly lower, the authors pointed out. Cancer accounts for about 5-6% of all healthcare expenditure, while cancer drugs make up 10-20% of total oncology spend and just 5% of all medicine costs, Jönsson noted, adding: “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 healthcare systems and pay for them.”

The report also highlighted the widening role of health technology assessments (HTAs) in determining access to innovative treatments, particularly in Europe and the UK. It gave a damning verdict on the UK’s National Institute for Health and Clinical Excellence, commenting: “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.”

Among the recommendations made by Wilking and Jönsson to make sure that patients across the world have swift and equal access to new cancer drugs are:

- Cutting review times for marketing authorisation.

- Ensuring that, once approved, drugs are available at national level without any further delays due to pricing and reimbursement negotiations.

- Making sure any economic evaluation or health technology assessment is done quickly “to facilitate, and not delay, patient access”.

- Ensuring “appropriate and adequate” healthcare funding is available for innovative cancer drugs, preferably on a proactive and not reactive basis.

Concerted efforts

From a UK perspective, the government has been making concerted efforts of late to parry accusations of a ‘postcode lottery’ in cancer care and of poor or patchy access to new oncology drugs.

An appraisal backlog at NICE hit cancer treatments particularly hard, so when the Institute introduced its Single Technology Appraisal mechanism last year, anticancers featured prominently among the 19 drugs referred for fast-track review. According to the Department of Health, around one quarter of NICE appraisals since 2000 have involved cancer drugs and the “large majority” of these have received a positive recommendation.

A review last September by England’s National Cancer Director found that the uptake of cancer drugs approved by NICE for use on the National Health Service (NHS) had improved by an average of 47% between July–December 2003 and January-June 2005. Moreover, variations in usage between cancer networks had narrowed for all the drugs in the survey.

Nonetheless, a manifesto published last November by the Association of the British Pharmaceutical Industry (ABPI) said the UK still lagged behind its European and global counterparts in prescribing new, innovative medicines. Even five years after their launch, major cancer medicines were still being prescribed at less than two-thirds the rate of other, comparable countries, the ABPI’s data showed.

Martyn Postle, director of Cambridge Healthcare & Biotech, thinks it is too easy just to lay the blame at the door of NICE. The Institute will always be on “a hiding to nothing”, he suggests.

The root cause of the problem is that the UK still spends considerably less on healthcare as a percentage of gross domestic product (GDP), Postle believes. ABPI comparison data for 2004 show the UK investing 8.6% of GDP in healthcare, compared with 10.6% in Germany, 10.5% in France, 9.4% on average across the original 15 European Union member states and 9.3% on average across the enlarged EU.

While the UK figure has risen since then, it is still likely to be trailing the country’s major European neighbours, Postle points out. Operating within these constraints, NICE is forced to come up with a ‘Schindler’s List’ of drugs that might best save lives with limited resources. “Perhaps NICE should be renamed NIEE (the National Institute of Economic Expediency),” he comments.

Cambridge Healthcare & Biotech has run several projects over the last few years looking a NICE’s approval process for anticancer drugs. “Our conclusion was that NICE always seems to recommend one generation back from leading edge therapies,” Postle notes.

“As soon as a breakthrough product arrives on the market (say a new monoclonal antibody product for a specific lymphoma), then this is often used as an opportunity for NICE to move its recommendations up a generation – presumably on the assumption that as therapies are replaced by more effective ones, then price competition for the older products becomes more intense.”