Q&A – About the series of reports on cancer and cancer drugs in Asia-Pacific

IHE has just published a series of reports on cancer and cancer drugs in Asia-Pacific. This region covers half of the world’s population and also accounts for half of all cancer deaths worldwide. The challenges are many and differ between geographic locations.

14 countries and locations (called “markets” in the report) are compared. They are grouped into 7 high-income markets (Australia, Hong Kong, Japan, New Zealand, Singapore, South Korea, Taiwan) and 7 middle-income markets (China, India, Indonesia, Malaysia, the Philippines, Thailand, Vietnam).

How big is the challenge with cancer?
Cancer is currently the leading cause of death in most high-income markets. We are also seeing an increasing proportion of people dying from cancer in middle-income markets. In total, the number of newly diagnosed cancer cases has increased from 6.6 to 7.8 million in the short period between 2012 and 2018 throughout Asia-Pacific. A population that is aging at a very fast pace means that more and more people are getting cancer, but an increase in unhealthy lifestyles such as smoking and obesity also play a role.

How good are the outcomes of cancer patients?
There are big differences between the markets. Out of every 100 patients diagnosed with cancer, approximately 50–65 survive in high-income markets, compared with 30–40 in middle-income markets. While outcomes appear to have improved in high-income markets recently, outcomes in middle-income markets seem to have stagnated.

What is the role of the health care system?
Access to cancer care is closely determined by how well-developed the health care system is. This refers to the proportion of the population covered by general health insurance, the health services covered and the size of patient co-payments. Australia, Japan, and New Zealand spend over US$ 3,000 per capita on publicly funded health care per year, while China spends ten times less (US$ 289) per capita and India is at the bottom of the list with US$ 20 per capita. Even in relation to GDP, high-income markets spend on average more than twice as much as middle-income markets.

What is the result of an underfunded health care system?
Observational studies in middle-income markets indicate that almost half of all cancer patients and their families suffer severe financial difficulties as a result of treatment costs and loss of income. In Thailand, “only” a quarter of patients and families face severe financial difficulties, which may be due to a well-developed public health insurance that provides access to cancer care services in both public and private care clinics.

What needs to be done?
In general, there is a strong positive correlation between how much money different markets spend on health care and outcomes of cancer patients (survival). Investments in all areas of cancer care – prevention, screening, diagnosis & treatment – are needed to meet future challenges. In high-income markets, prevention plays a major role in mitigating the rapid increase in new cancer cases due to the aging population. At the same time, a cost-effective use of existing health care resources is important. In middle-income markets, expanding general health insurance, starting to offer more modern health care services under the umbrella of the public sector, as well as improving the social safety net are priorities.

How good is the access to innovative cancer drugs?
Access to innovative cancer drugs, defined as drugs with a substantial clinical effect, is quite limited. Of the 38 innovative drug-indications approved by the US FDA for the treatment of five cancers, on average 80% had received regulatory approval by 2020 across Asia-Pacific. However, only 35% of the drug-indications were also reimbursed. High-income markets had much better access measured in terms of regulatory approval (91%) and reimbursement approval (59%) than middle-income markets (68% and 17%, respectively).

Why is the access so different?
All markets have different systems and different prerequisites. In Japan, all drugs are reimbursed per default no later than 2-3 months after regulatory approval. In New Zealand, this process usually takes 3 years or even longer, which is partly due to the fact that the public payer works on the basis of a fixed annual drug budget. In middle-income markets, limited access is due to low public drug budgets and the fact that very few new drugs are reimbursed. For example, China did not reimburse any new drugs between 2009 and 2017 and Vietnam none between 2015 and 2019. By comparison, around 10 new cancer drugs are launched each year worldwide.

What are the consequences of not having access to innovative cancer drugs?
Patients lose out on improved health and survival. Based on a sample of only 10 innovative drug-indications, the report shows that almost 1 million life years are lost across the region for each year of delay in reimbursement.

How much money is being spent on cancer drugs?
Again, there are major differences between the markets. Japan spent the most with over US$ 90 per capita in 2019 and South Korea spent the least among high-income markets with around US$ 30 per capita. Among middle-income markets, per capita expenditure levels varied between US$ 0.2 in India and US$ 6.6 in Thailand.

Why is so little money being spent on cancer drugs in middle-income markets?
This is partly because the list of reimbursed cancer drugs is very short and contains few innovative cancer drugs. India does not even have a public health insurance system that covers all of its population, meaning that many patients have to pay entirely for their drugs themselves – something which few can afford. Lower list prices of drugs and a lower number of cancer patients compared with high-income markets are further explanations for the large differences in per capita spending levels.

Do high-income markets spend enough on cancer drugs to meet patients’ needs?
The report investigates this issue through a case study of the drug pemetrexed, which has been used in the treatment of lung cancer for over 15 years and for which generics have just been launched. In recent years, this drug started to be used in combination with immunotherapy in Australia and Japan following a positive reimbursement decision. But both markets only seem to provide the combination to half of all patients in need. In other high-income markets but also middle-income markets where pemetrexed is only reimbursed in combination with platinum, patients’ needs are met. In middle-income markets where pemetrexed is not reimbursed, less than 10% of patients’ needs are met.

If middle-income markets cannot afford to spend more money, what ways are there to increase access to new and innovative cancer drugs?
One way that the report examines are pricing mechanisms for drugs after patent expiry. Large price reductions after the patent expires can generate significant savings. This frees up resources that can instead be used to pay for new and innovative cancer drugs.

How well do markets achieve an effective pricing of cancer drugs after patent expiry?
In general, the price of the original drug falls in all markets after the patent expires. However, the magnitude of the price reduction varies considerably across both drugs and markets. If all markets had achieved the same lowest price as observed for the original drug in any of the markets, all markets would have been able to save between 5% and 20% of their total cancer drug expenditure. These are large sums of money and are based only on a selection of 11 top-selling cancer drugs with patent expiry between 2010 and 2020.

Published IHE Reports on cancer care and access to cancer drugs in Asia-Pacific:

Cancer care and access to cancer drugs in Asia-Pacific – Main report
IHE Report 2021:3, IHE: Lund, Sweden

Cancer care and access to cancer drugs in Asia-Pacific – Introduction
IHE Report 2021:3a, IHE: Lund, Sweden

Cancer care and access to cancer drugs in Asia-Pacific – Executive summary
IHE Report 2021:3b, IHE: Lund, Sweden

The burden of cancer in Asia-Pacific
IHE Report 2021:3c, IHE: Lund, Sweden

Health spending on cancer in Asia-Pacific
IHE Report 2021:3d, IHE: Lund, Sweden

Patient access to innovative cancer drugs in Asia-Pacific
IHE Report 2021:3e, IHE: Lund, Sweden

Health spending on cancer drugs and unmet patient needs in Asia-Pacific
IHE Report 2021:3f, IHE: Lund, Sweden

Pricing policies for off-patent drugs in Asia-Pacific
IHE Report 2021:3g, IHE: Lund, Sweden

For more information, please contact Thomas Hofmarcher