Drug innovations in recent years have led to huge increases in overall and progression-free survival in once-deadly diseases. Ten-year survival for some cancers, such as melanoma and prostate cancer, has doubled or even tripled in the last 40 years, while diseases such as hepatitis C and HIV have become chronic conditions. However, while survival is obviously a good thing for patients, it can bring many difficulties.
Julia Frater, Cancer Research UK’s information nurse, offers some examples. “Cancer treatments can leave ongoing side effects that impact people’s lives. Just having cancer can also affect patients’ lives, both emotionally and practically. For example, during or after treatment some patients may not be able to work in the same capacity as before and so may earn less. Some treatments take up a lot of time and need regular hospital visits,” she says.
More patients in need of treatment and monitoring over longer periods of time can also put a strain on the healthcare system, adds Dean Summerfield, senior vice president, commercial and consulting at Quintiles. “The additional costs passed to the individual, their families and carers, and to the healthcare system are becoming a significant challenge,” he says. “The strain comes in multiple ways; for example, many new, complex therapies require a degree of testing, not just at initial diagnosis and treatment but throughout the progression of the disease.
Because of the improvements in survivorship we’ve also seen increased willingness to seek help, which puts an increased strain on resources at the initial treatment stage.”
Pharma’s helping hand
When survivorship leads to increased costs for patients and the healthcare system, there are inevitably questions about what pharma can do to help ease that burden, says Summerfield. “Our research looking at the emotional journey in diseases such as multiple sclerosis shows that a lot of emotional support is quite rightly needed. The expertise to provide it exists within the NHS but it also exists within the industry, which has different connections. It can provide new services to help play a bigger part in realising the benefit, and offsetting the burden, of increased survivorship. This will become much more important if the period between diagnosis to death becomes much longer and we see people spending a longer time on that journey.”
Summerfield suggests that the debate about collaborations between the pharmaceutical industry and the healthcare system should be reopened, to see if together they can prevent the additional costs of survivorship being a block on the main benefits of a drug. He cites Pfizer’s funding of testing facilities for its drug Xalkori (crizotinib) in Wales, although they have since been discontinued after the drug was no longer being funded.
“Because of some of the challenges of trust between the different players it’s not been as progressive as it could have been,” he adds. “You see the willingness on the pharmaceutical industry’s side to be more involved, but we need to re-energise that dialogue to see if more can be done.”
The cost to society
Pharma itself may also feel the implications of increased survivorship, particularly as longer life expectancies change how the value of drugs is assessed. “When we’re doing the health economic modelling for a NICE submission we’re projecting over a significant number of years and once we get beyond 12 to 24 months a lot of assumptions are made,” says Summerfield. “In the UK and other markets that ask you to think of societal costs and benefits, we’re starting to see an increasing gap in the evidence and the available knowledge.
“When Roche’s Perjeta (pertuzumab) was evaluated by NICE there was a huge debate about assessing QALYs because it was an adjunctive therapy to Herceptin (trastuzumab). Herceptin’s price was based on seven months but suddenly you need to take it for another 16 and add Perjeta on top. Just treating those patients for that length of time involves more tests, more patient burden, more costs, more carer costs etc,” he says.
Summerfield anticipates that regulators will start to ask for greater levels of evidence on the costs and savings related to survivorship. “Collecting data might not just be focused on the treatment of the disease, but more holistically around the impact on patient lives. We need to think about how we can model that.”
This has already started to happen in some areas. In 2014, US senators launched an investigation into the price of Gilead’s $1,000 per-pill hepatitis C medicine Sovaldi (sofosbuvir), asking the company to explain its pricing methodology and impact on public health. They eventually concluded that the massive increases in survival afforded by the drug were not enough to justify the price tag and that Gilead’s strategy had focused on maximising revenue.
For Summerfield, alliances and data sharing could help address this. “A lot of these innovations come from smaller companies in targeted disease areas, which may not meet the classification of a rare or orphan condition but still have a relatively small patient population, so providing this evidence can be quite difficult. Maybe in the disease registry space we’ll have non-competitive alliances to share information and provide healthcare systems with this evidence,” he says.
It’s easy to focus on the excitement surrounding drugs that fundamentally change the landscape of a condition, but it’s also important to look at the bigger picture and consider what the impacts will be across the healthcare system, from patients to healthcare and pharma. That way, the entire sector can be best placed to provide even more life-changing medicines in the future.
