Tag Archives: equity

“The purse is closed!” – this is no way to run a hospital

Rosa Giuliani, medical oncologist, S. Camillo-Forlanini Hospital, Rome, Italy

Rosa Giuliani, medical oncologist, S. Camillo-Forlanini Hospital, Rome, Italy


As a medical oncologist my primary interest is in helping patients to live longer and better. The best part of my job is the integration of clinical and molecular views: see the problem in the clinic, look for answers in the lab, bring back the solution to patients. I wish it could be as simple as that.

Research & development have a price, which is often difficult to understand. Why new drugs and devices cost that much, and not a penny less, is a complicated conundrum for many of us. The EU regulatory and reimbursement systems, the lack of a universal health policy through Europe and the profound economic crisis are regularly debated.

While I was at ECCO participating in debates on the need to promote equity and defeat disparities in access to precision medicine in Europe, hospital managers where I work notified the oncology department that the budget allocated to cancer drugs expenditure was over:no “expensive” drugs could be purchased until the budget for the new year will be discussed in January. The purse was closed. Meetings followed, some very unpleasant; poor use of resources by medical staff was implied, not even too subtly. Of course, this prompted self-examination: am I a good oncologist? Am I following guidelines? Am I spending money for my pleasure to give drugs?

After this last question, I realized that I was losing my mind and luckily, I returned to my senses. I respect rules, I need rules, I love rules. I appreciate fair rules. Budget negotiations at local hospitals are as obscure as the procedure of setting prices at EU or national level. A rule, which lacks of transparency, is not fair. The fact that the rules are set and dealt by people who are not prepared to manage the process, is terribly wrong. The overwhelming gap between cancer politics at EU Headquarters, where precision medicine is being promoted, and cancer politics at local level, where the only interest is that 2+2 should be equal to 3, because 4 is already too expensive, is frightening.

Money is an important part of the equation: resources are not infinite and their rational employment is of utmost importance. The process of drug development is not cost-effective, and many managers are not, because they have not been adequately prepared to deal with a different type of economy. Cancer medicine cannot be dealt as if providing water or electricity.

The global curriculum for being a good medical oncologist has dramatically changed in the past 10 years. Medical oncologists in 2015 cannot neglect molecular biology, health policies, precision medicine and so on. The same change should happen with managers who allocate resources for health politics, especially at hospital level. Being a good accountant does not suffice anymore, just as being exclusively a good clinician is not enough. Another level of knowledge and preparation is needed. And honestly, sometimes, a little bit of emotional intelligence would not do any harm.

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An essential cancer medicines list for Europe


Martine Piccart

Patients are still waiting to feel real benefit from the rapid advances in knowledge and technologyseen over the past decade. This October, 50 experts from across the globe involved in researching, developing, evaluating and delivering new therapies will meet to develop consensus recommendation on who needs to do what tospeed the development of effective treatments. The meeting is one of a series of World Oncology Forum summits organised by ESO in collaboration with the Lancet.

How can we improve access to important new cancer therapies? Martine Piccart – president of ECCO and past-president of ESMO, argues the case for a WHO-style essential drugs list for Europe.

WHEN I BECAME PRESIDENT OF ESMO (European Society for Medical Oncology) in 2012, I had on my agenda to visit countries of eastern Europe, because I was shocked by statistics indicating that even inside Europe there are significant differences in cancer outcomes between the western and eastern parts.

Of course there are huge discrepancies between Europe and Africa, for instance, but that this exists inside Europe came as a shock, so I decided to travel to the countries and talk to the oncologists there.

I will be talking at WOF about what I learned from them about their efforts to improve access to new therapies, and how that prompted ESMO to develop a rating scale to evaluate the magnitude of benefit of new anti-cancer drugs for solid tumours.

Which would I choose?

The idea is to help oncologists focus their lobbying efforts on the most important therapies, and also to strengthen their bargaining position, because they can show that the therapies they are asking for are considered to be very important by the wider medical oncology community.

It’s taken us more than a year to come up with something that we are beginning to be happy with. And we’re now awaiting input from patient organisations about rating impact on their quality of life.

It’s a first attempt at getting a community of oncologists to look at all the very expensive drugs that we have seen in development in the last 10 years and really asking the question: if I have to choose only a few, which ones am I going to choose.

Potential dangers

As I will explain, this was an interesting exercise. When you start something like that you think it is going to be easy, but then you discover that it is actually incredibly complicated and there are potential dangers. For instance, we don’t want it to be used by governments in an aggressive way, to decide that they are only going to pay for one or two top-scoring drugs and never for the others.

What I hope to present at WOF is the reasoning behind the development of the scale, and how we went about it, and why we think it will be important. And I’m looking forward to the discussion.

Convincing governments

More generally, I hope that WOF won’t just look at what needs to be done, but also how to convince governments and politicians to take the necessary action.

We need to be able to show them how outcomes for citizens in their country compare with what is being achieved in other parts of Europe, to bring home the consequences of lack of access to the right treatments – and this is not just about new drugs but also the basics of high-quality surgery and radiotherapy. I think this kind of language is more powerful for politicians than simply going to them and saying we need money and we need new innovative treatments

These sorts of comparisons require high-quality cancer registries with homogenous cancer data – something I was shocked to find out still doesn’t exist in many European countries. So I think more support for high quality registries must be one of the messages from this WOF.

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