New and better drugs to treat diseases such as advanced breast cancer1 will have little effect on improving patient outcomes if a country does not have good healthcare structures in place, Professor Richard Sullivan told the Advanced Breast Cancer Third International Consensus Conference today (Friday).
Without good systems, Prof Sullivan, of the Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, King's College London (UK), said there was little point in even discussing whether breast cancer drugs were affordable or not. "As things stand, I think many of the new molecular targeted agents are not affordable to many European countries, and this is only going to get worse."
However, in a second presentation, David Taylor, Emeritus Professor of Pharmaceutical and Public Health Policy at the University College London School of Pharmacy (UK), told the conference that although individual drugs can appear to be expensive, their cost is offset by many other drugs becoming cheaper over time as their patent protection expires and, overall, the spending on drugs at national and global levels remains stable. Although, in richer countries, the spending on medicines has grown in absolute terms, it has remained stable as a proportion of gross domestic product (GDP).
"If we want to afford better medicines for women with advanced breast cancer, we can do that," he told the conference. "Of course, new treatments can be expensive for individual budget holders, and there may always be arguments about prices, but, given that we are now close to developing definitive treatments for many cancers, I have no doubt that it is right for richer countries to continue investing through purchasing innovative therapies. One of the unique advantages of medicines is that, although they appear expensive when first introduced, their cost falls to lower levels after the patents that are needed to encourage and fund further research expire. This is not normally true of any form of health or social care that has high labour costs."
Prof Sullivan believes that the discussion about improving healthcare structures, particularly around surgery and radiotherapy, has to come before that about the affordability of individual drugs.
"Talking about medicines makes sense if you are a patient accessing a safe, well-regulated, well-governanced, well-provisioned work force - then you can have the argument about the costs of medicines," Prof Sullivan told the conference. "But if you are a patient in a country where the healthcare system is unregulated, chaotic, with no transparency and no way of looking at outcomes, then this becomes an irrelevant argument. If you haven't got a good healthcare system with firm foundations, then no amount of new medicines or new interventions will improve patient outcomes."
He said a certain level of investment in healthcare was important, but after that what really mattered was how the money was used. "There are countries like Romania that have had no improvement in their outcomes for breast cancer over the last decade, but they are putting no money into the system. Then you get the other situation where a country is putting money into the system and a reasonable amount of money into its breast cancer care system, but there doesn't seem to be a correlation with outcomes, and this is because you have got to connect the money to structural reform. So you get this ridiculous situation where Greece is now spending the biggest amount in Europe, but it has made no structural reforms, and you see little improvement in their breast cancer outcomes."
He said breast cancer treatment and outcomes could be used as indicators of the health and strength of a country's cancer care system generally. "From a healthcare system and global perspective, increasingly breast cancer acts as a bell-weather disease. It's an indicator of how well healthcare providers adhere to treatment guidelines and audit their outcomes, the availability of general and specific care, radiotherapy and medicines."
Looking at breast cancer in this way in order to understand how well a system is working and what needs to be done to improve it provides policy messages not just for European countries, but also for other, under-resourced or emerging economies such as eastern Europe and India, said Prof Sullivan.
"The economics of breast cancer can be a way of looking at a system, understanding where the priorities are and who is doing what. It's also the single biggest lever for changing things," he said. "Convincing governments that losing women to premature death and other illnesses and conditions resulting from the disease costs them a lot of money is the only thing that's going to bring about change. We also need to quantify the costs of informal care and direct healthcare. The informal care costs are about the impoverishing effect that breast cancer has on the family beyond the loss of the woman, and the direct healthcare costs are about ensuring that as you put money into your systems of care, you get the best value in return. It's about being logical about your expenditures. We see too many countries saying they have to have the very latest breast cancer medicines, and I think that's deranged! Where's your surgery, where's your early diagnosis, where's your radiotherapy? Forget medicines - if you haven't got those basic building blocks in place, it's a waste of time even discussing an essential medicines list for breast cancer."
Prof Taylor said: "In India, breast cancer has overtaken cancer of the cervix as the main killer of younger women. Given adequate disease detection and initial surgery, it should be possible to get low cost tamoxifen 2 to large numbers of women without having elaborate structures in place. This could save lives. But in principle, I would agree that drugs alone are never a good answer. At present you have got to have many other elements of cancer services in place before it is worth spending limited national resources on most of today's sophisticated, but essentially palliative anti-cancer drugs."
Co-chair of the conference, Professor Fatima Cardoso, Director of the Breast Unit of the Champalimaud Cancer Centre in Lisbon, Portugal, said: "Access to high quality anti-cancer care is one of the hot topics of the moment. Unfortunately, inequalities in access continue to increase both between countries and within each country. For patients with advanced breast cancer this is even truer. Organisation of care is mainly focused on screening and early detection, not on metastases; tumour board discussions are held mainly for early breast cancer cases and every new treatment is rushed to the early setting, without proper exploration of how to truly improve the survival of advanced breast cancer patients.
"Affordability is a multifaceted problem for which different solutions must be found urgently through a joint effort by all involved."