‘Is cancer different? Costs, benefits and who pays?

James Raftery,Professor Health Technology Assessment,

University of Southampton

Themes• “onco-exceptionalism” - only if more cost

effective?• Cancer screening• Cancer drugs• NICE and cancer drugs• The oppportunity costs of exceptionalism• Ways forward

Ireland’s 3 cancer screening programmes

• Breast Screening Programme free (mammograms) women aged 50 to 64 every 2 years. Aim to include up 69.

• Cervical Screening Programme aged 25 to 60 on 1 September 2008. free smear tests every three years to women aged 25 to 44. Following two consecutive ‘no abnormality detected’ results, women aged 45 to 60 are screened every five years.

• The National Bowel Screening Programme. offers free bowel screening to men and women aged 60-69.Aim 55-74. 2 yearly

• + “opportunistic” prostate cancer screening

Broadly as England…..• But Breast: more restricted age range, Cervical post 44,

Colorectal phasing different• Prostate cancer screening: US, UK decided against

formal screening programme• But PSA testing common, especially Ireland• “Screening is highest in those with highest

socioeconomic status and educational attainment, and who also hold private insurance cover.”

Harms from cancer screening• All screening imposes harms and benefits• Inconvenience, False +, overtreatment, worry• Overtreatment –treat “indolent” cancers• Most serious with breast screening due to surgery/mastectomy……

less so with lesions in colorectal & cervical?• UK 2012 review pro on balance• But Norway study (in press) shows longer terms harms re worry

and employement• Irish study shows financial harms

Overtreatment• Mortality stays same but incidence rises

Conclusions to study comparing Ireland and N. Ireland “Prostate cancer Incidence was consistently higher in the RoI than NI The difference in incidence mainly due to the relative intensity of cancer

investigation via prostatic biopsy, rather than PSA testing 1994-2000, PSA rates similar, but incidence higher in the RoI PSA testing was increasingly used in NI before 1999, but no rise in incidence until

1999 very low biopsy rate in NI in 1999; incidence rose as biopsy rate rose higher biopsy rate in the RoI – and higher incidence in RoI, age-specific trends in incidence mirror those for biopsies evidence that threshold for biopsy lower in RoI

o lower median PSA level in those with cancero studies among primary care physicians (Connolly, 2007 MD thesis; Drummond

et al. BMC Fam Pract 2009) and urologists are consistent with this o consistent with differences in healthcare system”

Cancer drugs- modest gains, high prices

• All new solid tumor drugs 2002-14 approved in the USA: median gain in the progression free period 2.5 months, median gain of 2.1 months extra life (Fojo et al 2014)

• $500,000 for a year of life in good health gained• 12/13 new cancer drugs approved in US in 2012

>$100k

“But it costs $2.6b to bring pill to market….”

• Standard pharma case for high prices• Tufts study puts cost at $2.6b ….not believable (Light)• But half due to cost of capital at 10% (!!)• Truth is firms charge what the US market will bear• Some signs of rebellion due in part to co-payments

and contracting out• But

NICE and cancer drugs• NICE refuses few drugs wholly (16%) or in part • But problems with cancer drugs led to 2 changes:

End of Life criteria and Cancer Drugs Fund• End of Life criteria: doubled the cost/QALy threshold• CDF: funds cancer drugs refused by NICE. Reduced

the NICE refusal rate to 7%

2014 Cancer Drugs Fund• Funding increased to £280 per year to 2016• “CDF’s panel of experts re-evaluate a number of drugs currently on

the list”, • incentivise responsible pricing by drug companies. • We want to create a sustainable Cancer Drugs Fund”• to develop options for ensuring greater alignment between CDF

and NICE assessment processes. • The CDF panel will also develop options for a new “Evaluation

through Commissioning” scheme.

Drugs at “End of Life”• NICE 2009 provisional No to four drugs—bevacizumab, sorafenib, sunitinib, and

temsirolimus—for advanced/metastatic renal cell cancer• NICE was required by government to issue new criteria for drugs at the “end of

life”, defined as• Life expectancy less than 24 months,• Gain from treatment of at least 3 months,• Small patient population, and• No alternative treatment with comparable benefit available through the NHS.• NICE said yes to Sunitinib at cost/QALY $100k or double nornal• By 2012, 14 drugs met the criteria, 9 were approved, costing the NHS £650m pa.

(Latimer BMJ)

Opportunity cost of exceptionalism• If health budget is fixed, then spend more on X (cancer)

means spend less on Y (the rest)• Difficulty is those denied other treatments are anonymous• Identify/defend those denied cost effective treatments • IN NHS, elective surgery for hips, knees, varicose veins,

hernia surgery: £/QALY<£10k• Best estimates put NHS £/QALY <£15k.• If so NICE doing harm with threshold £30k/QALY

Ireland’s health system• Mix of public (78%) and high (22%) private • Strong role of private providers, voluntary

hospitals. • No/weak NHS ethos• Move to social insurance: cost $3k/person 2012• Debate on future of Irish healthcare should face

how much to spend including on cancer.

What to do?• Ongoing challenge, with prices depending mainly on US market • which is 50% of global market, least regulated• “if you want to learn about improving healthcare, don’t start

here” (U Reinhardt)• Irish health system: more Boston than Birmingham (or Berlin)• All systems struggle to feature opportunity costs• One option: set cancer budget? Trade off chemo, radiation

therapy, palliative care, screening

References• 1.Burns R Walsh B, Sharp L O’Neil C Prostate cancer

screening practices in the Republic of Ireland: the determinants of uptake Health Serv Res Policy October 2012 vol. 17 no. 4 206-21 doi: 10.1258/jhsrp.2012.011105 J 1

• Light D, Warburton R Demythologising the high costs of pharma research BioSocieties (2011) 6, 34–50. doi:10.1057/biosoc.2010.40; published online 7 February 2011