Tag Archives: healthcare

Extreme oncology in Romania

Geta Roman is a Bucharest-based freelance journalist writing about history and medicine. For more than 10 years she was a health editor for Romanian newspapers Cotidianul and Evenimentul Zilei

Geta Roman is a Bucharest-based freelance journalist writing about history and medicine. For more than 10 years she was a health editor for Romanian newspapers Cotidianul and Evenimentul Zilei

Being an oncologist in Romania is an extreme job. Being a patient with cancer in Romania is an extreme experience.

We have 250 oncologists to care for at least 500,000 people with cancer (the figures are uncertain because the National Cancer Registry is not up and running). Our hospitals are crowded, we lack medication, many patients waiting for chemotherapy or radiotherapy, and doctors and nurses are overwhelmed. At the same time, oncology is a field rife with corruption, with the patient caught in the middle.

The National Health Insurance and Ministry of Health are trying to find solutions: more money has been offered to doctors who work in emergency departments, and the private sector is now involved in providing radiotherapy and chemotherapy treatments, paid for by National Health Insurance. But it’s nowhere near enough to resolve the crisis in our cancer services.

The young doctors who are preparing to take the place of the older generation when they retire, and the older doctors who are forced to care for more patients than they can handle, propose the same solution for resolving this crisis: more money for doctors’ salaries, to keep them from leaving the country.

An experienced oncologist earns around €1,000 per month working in the public health system, while the younger ones earn only around €300-400 depending on their experience.

Flori Vladutescu is a Resident doctor in her second year in one of the biggest hospital in the country. She chose to become one because of the impact of cancer on her own life: her mother died from breast cancer when Flori was only four years old, and in the past years she has given close support to her sister, who was diagnosed with stage III breast cancer. She would like to know whether they have the breast cancer gene mutation, but the tests are too expensive, and are not covered by the public system.

Right now, Flori has decided to stay in Romania to care for people with cancer. She’s been promised a job in Giurgiu, 60 km from her hometown, Bucharest. “Cancer patient are special, more sensitive, you have to work with them to solve the physical problems, but you need a special attitude. I learnt that from my oncology teachers, who are also different – nicer, more human…” says Flori.

Initially she had intended to leave the country after finishing her residency. But she changed her mind, and is set on taking the job in Gurgui. “I’ve already gone there. I met the doctor who I will work with, and I saw all those patients who need help. I felt for them.” Her biggest challenge, she says, will be how to manage financially. “Half my salary will go on petrol, if I choose to commute from Bucharest every day” She think she may look for somewhere more local to stay.

“Half my salary will go on petrol”

The doctor in charge of the oncology outpatient clinic in Giurgiu, Florin Onisim, says that poor organisation ends up wasting doctors’ time, making an impossible job even more impossible. A new system of electronic registration was implemented over the past year, but no additional staff were recruited to input all the data. “It is extremely bureaucratic,” says Onisim. Before this system, I was able to see 70 people daily, now only around 30–35,” he says.

People living in and around Giurgiu are relatively lucky in one respect – they live not far from Bucharest, which has the biggest concentration of public and private cancer services in the country, so most of them have the option to travel to find an expert.

The situation is worse in other parts of the country. In Vaslui, one of the poorest cities, along the eastern border of Romania, the county hospital – which caters for a population of 375,000 – has no oncologist at all. In Resita, a city with 65,000 people, in the west part of Romania, the only oncologist in the area is responsible for the more than 8,000 patients recorded in the cancer registry.

Every time the local authorities try to hire oncologists, they face the same obstacle: no doctors are interested in going there, because of the low salaries offered by public hospitals. They prefer to join the exodus of more than 10,000 doctors who have gone to work in other European countries since 2007, when Romania became an EU member. Or they stay and work in the private sector in Romania.

The solution to both is better payments for doctors.

Cancer patients receiving chemotherapy at a major Bucharest hospital

Cancer patients receiving chemotherapy at a major Bucharest hospital

The EU’s cancer community: better with the UK?

Marc Beishon

Marc Beishon

Next week the people of the UK will vote on whether to remain in the European Union or leave it, a decision that could have far reaching implications for the future of the European ‘project’. In the UK, there has been increasingly bitter exchanges between the two camps about whether the country (or indeed the four constituent countries) will be better or worse off if there is a leave decision, and many misleading and often untrue financial figures have been put forward as ‘fact’.

While there has been little debate on what general shape the EU will be in following a UK exit, there has been some revealing discussion about some aspects of European-wide cooperation, notably research, and cancer research in particular. There has often been debate about how good Europe is at uniting cancer research to rival the powerhouse that is the US, and now some are arguing that the UK, as the leading biological research nation in Europe, may undermine progress if it were to leave the EU, and could also harm its own efforts to raise healthcare standards.

Writing in Lancet Oncology, five senior cancer and biomedical researchers, including Nobel laureate Paul Nurse, note that the UK has learnt about better care from other European countries, given it has lagged in outcomes for some time; has participated in more than 80% of cancer projects funded by the EU’s 7th framework programme; and generally, “the benefits of these collaborative European approaches so far have been major and can still increase, and are greatly facilitated by the EU”. But while much collaboration should continue, UK researchers may not be able to access EU funding, and free movement of cancer researchers between the UK and Europe could be halted.

Also in Lancet Oncology, Josep Tabernero and, Fortunato Ciardiello – the latter the current president of the European Society of Medical Oncology (ESMO) – argue that the broader aims of spreading research monies from the Horizon 2020 seven-year science programme, the biggest EU research programme in history, around Europe could be at risk from ‘Brexit’. They say too that the European Medicines Agency, currently based in London, would have to find a new home. “Post-exit uncertainty would inevitably affect European oncology research and care and would necessitate a lengthy period of adaptation as we grapple with the aftermath,” they say.

It is certainly also possible that EU institutes such as the Joint Research Centre, which carries out much work on areas such pan-European cancer information databases and the European Commission Initiative on Breast Cancer, could suffer.

But Angus Dalgleish, professor of oncology at St George’s University of London, has pointed out that the seven of the top nine universities are in the UK, which is unlikely to change, and European collaboration in science has been in place long before the post-Lisbon Treaty EU. “Examples abound, such as CERN, the European Molecular Biology laboratories, the European Organisation for Research and Treatment of Cancer (EORTC) and the European Space Agency,” he says. “It is a myth to think that if we left the EU we wouldn’t be part of these great collaborations, which already include many countries that are not in the EU, such as Switzerland, Norway and Israel.” (Note though that Dalgleish is also a member of the UK Independence Party.)

He would probably point too at Cancer Core Europe, the new group of elite cancer centres in Europe, including Cambridge, that is pushing ahead with large scale collaborative research.

And certainly there has been much frustration with the EU, in particular with the much criticised clinical trials directive of 2001. But that was reformed in 2014, and then just recently the European Parliament has adopted the EU General Data Protection Regulation (GDPR), which ESMO describes as “crucial” for the future of cancer research as it includes one-time consent for retrospective research on clinical data and biological tissues, and aims to harmonise the different frameworks governing health research across the EU’s member states. Under the current Juncker commission in Brussels there is also a commitment to weed out unnecessary regulation.

If the UK does vote to leave, there will be several years of negotiation and perhaps the country will continue to participate in EU research programmes as before, and it will certainly have to conform to regulations such as the GDPR in international work that involves Europe.

But whichever way the vote goes, one positive result is that Europe’s cancer community has come under renewed focus from several angles – workforce, research and care – even if its value under the EU umbrella is contested.

The price isn’t right, but neither is the effect

Marc Beishon

Marc Beishon

 

Concern about the high prices of cancer drugs is nothing new but there are signs now that the issue may be coming to a head. There is a flood of new agents coming onto the market and, if anything, the prices charged are still going up, with more agents reaching eye-watering levels above $100,000 a year. Global annual spending on cancer drugs has now hit $100 billion for the first time.

At the upcoming European Cancer Congress, a study by a UK pharmacologist on how much it costs to make cancer drugs such as imatinib (Glivec) will reveal that Americans in particular are paying hugely more than the manufacturing cost, but Western European prices are also high.

Just a few weeks ago, a group of more than 100 senior oncologists, mostly in the US, launched a ‘grassroots’ petition calling on the powers that be in America to address the harm that high drug prices cause patients. Writing in Mayo Clinical Proceedings, the oncologists says the average price of new cancer drugs in the US increased 5- to 10-fold over 15 years, to more than $100,000 a year in 2012 and the cost of drugs for each additional year lived (after adjusting for inflation) has increased from $54,000 in 1995 to $207,000 in 2013.

Of course, the US has particular conditions that determine drug prices – its Medicare system for older people is not allowed to negotiate prices, and the lack of a universal healthcare system means many patients are faced with huge ‘co-pays’ on drugs through their private insurers. As the Mayo article says: “For a patient with cancer who needs one cancer drug that costs $120,000 per year, the out-of-pocket expenses could be as high as $25,000 to $30,000.” In calling for people to sign the petition, the oncologists say: “The individuals most harmed and least engaged in these discussions are cancer patients because they are exhausting their energy, resources, and time fighting for their lives,” and note that advocacy proved successful in stimulating treatments for those affected by the AIDS epidemic.

Cancer drug prices are of great concern elsewhere, of course. In European hospitals and healthcare systems the pressure on budgets for new drugs is great. In the UK, for instance, there are endless arguments over reimbursement for new treatments. In 2011 the government resorted to setting up a special cancer drugs fund for England to pay for treatments that the National Health Service would not otherwise fund.

At European Union level, there are a string of initiatives, such as the new European Commission expert group on Safe and Timely Access to Medicines for Patients (STAMP), which in turn is hearing updates on various projects such as the European network for Health Technology Assessment, and the network of Competent Authorities on Pricing and Reimbursement. But joint negotiation of pricing among countries, which could lower cost, is not in the Commission’s remit, although there is a joint procurement agreement for vaccines and other “medical countermeasures”. There is though a move by Belgium and the Netherlands to engage in joint drug price negotiation, initially for orphan drugs, where small patient numbers can mean high prices, and which will also involve cooperation on registries and evaluation.

The US oncologists propose a number of actions that could help, including price negotiation, allowing drug imports, faster access to generics, a reform of the patent system, and perhaps most importantly, taking steps to include both the cost and efficacy of drugs in assessments of treatment value and in guidelines. In fact, England already has what many countries, notably the US, lack – a body that recommends reimbursement only for treatments that meets value for money criteria, namely the National Institute for Health and Care Excellence (NICE), which uses QALYs (quality adjusted life years). But the hasty establishment of the cancer drugs fund shows that the pressure to access treatments beyond NICE’s recommendations (and the NHS budget) is great, as stories about patients denied drugs flood the media.

The high price of cancer drugs would of course be less of a problem if they were more effective, but breakthroughs have been the exception not the rule. As Fatima Cardoso, co-chair of the Advanced Breast Cancer conference, has recently commented in Cancer World: “In early breast cancer the standards of care haven’t changed in more than two decades; in advanced disease median overall survival is still a dismal two to three years.”

Certainly, more can be done to add to measures of drug effectiveness. This year, the European Society of Medical Oncology introduced the first version of the Magnitude of Clinical Benefit Scale (MCBS), which grades therapies with both curative intent and palliative intent, and which its developers say is a validated tool that can be used to prioritise drugs for assessment and develop clinical guidelines founded on magnitude of benefit rather than just level of evidence. A quick check on several grade 4 (out of 5) palliative drugs in the MCBS shows they are also recommended by NICE, so there may be some duplication here, initially, although at least one with a grade 5 score, the breast cancer drug Kadcyla, was turned down by NICE owing to its very high price and is now one of several drugs cut from the NHS cancer drugs fund.

Meanwhile in the US, the American Society of Clinical Oncology (ASCO) has just launched a framework for assessing the value of new cancer therapies “based on treatment benefits, toxicities and costs”. Developed by ASCO’s Value in Cancer Care Task Force, this aims to be a “user friendly” tool that oncologists can use with patients to discuss the value of new treatments compared with standard ones, and has been out for consultation. A paper in JAMA Oncology has also looked at how applying a value-based cost can work in a drug used in metastatic lung cancer, but political forces in the US are hard to influence along these lines.

Along with efforts to pin down cost-effectiveness and to carry out more meaningful clinical trials, Cardoso says a priority is to ensure that each patient is treated according to current knowledge and guidelines, which is often not the case. And in England, Karl Claxton, an economics professor specialising in health technology, has published research that calls into question the cost-effectiveness threshold that NICE uses – saying that it is in fact too high. His study made the news, as the implication is that some money spent on cancer drugs, and particularly the drugs funded by the special fund, would be more effectively deployed across the health system, both on standard cancer care and other health conditions.

The UK’s NHS has had long battles with drug companies over price but drugs are also rejected because of lack of effect. Were the US to take similar steps to agree on what constitutes an effective new therapy then there could be a move towards more meaningful drug development as well as lower prices for patients. As the authors of the ESMO MCBS paper also say: “A key challenge for the future will be to establish whether there can be harmonisation between the different approaches to value in Europe and the US.”

 

 

 

Speeding up global access to detection and care

 

Dr Rengaswamy Sankaranarayanan

Dr Rengaswamy Sankaranarayanan

Rengaswamy Sankaranarayanan, special advisor on cancer control and head of early detection and prevention at IARC (the WHO’s International Agency for Research on Cancer), Lyon, will lead the session on Access to effective and affordable treatments in middle- and low-income countries at the World Oncology Forum, Lugano, October 23–25. In this guest blogpost he talks about the policy recommendations he will be arguing for.

I’M LOOKING FORWARD to speaking at the World Oncology Forum about new healthcare financing models that are extending access to effective early diagnosis and treatment of cancer in many low- to- middle-income countries. I would like to see the Forum issue recommendations that can catalyse the pace of this transformation and deliver a very blunt message to governments and international development agencies.

Some success stories

The last few years have seen important progress in access to healthcare, particularly in middle-income countries. I would like to see this replicated in low-income countries.

Thailand, for instance, started introducing universal healthcare from 2002. Today, anyone living anywhere in Thailand, can access care seamlessly across public health services.

Initially under the Thai scheme, people were required to make a single, small copayment – 30 Baht or around $1 – the first time they see a healthcare professional for a particular complaint. That payment would cover the entire journey that follows, including diagnostic tests, treatments and follow-up. This co-payment was abolished in 2007, and universal health care became free for poor people.

Despite initial fears that the health system would collapse, it is working well. One important reason is that the government is investing a substantial amount of its GDP into healthcare. Another is that the “30-Baht” scheme mainly covers people from the very poorest rural communities – those employed by the government and the private sector have their own insurance systems.

Not only has it considerably improved access to healthcare in Thailand, it has also regulated the market, because the system will only pay for standard procedures. Since then, many other middle-income countries have implemented successful schemes to widen access to healthcare, including Turkey, India and Malaysia as well as many of the larger countries in Latin America, such as Mexico, Brazil, Colombia, Peru, Argentina and Chile.

Spreading the success: two recommendations

1. Cancer control must be a national responsibility

Countries like Thailand have shown it is possible through a variety of models to provide sustainable good-quality health services on a subsidised basis for a large proportion of people, while recovering healthcare costs from those who can afford it.

However, we also need to learn from our failures. In sub-Saharan Africa, for instance, health services have barely improved, there are no health financing systems, and access to healthcare has not improved at all.

I think one of the major reasons for this is the amount of external assistance they receive, which has blunted internal investment and internal drive and internal planning.

We need to make governments realise that healthcare is their own responsibility, and the systems and investments they have to make should be their own, and should come from their own national budgets. The way to do this is to substantially increase the GDP proportion that is contributed to healthcare from national budget.

So one message I would like to come out of the World Oncology Forum is that:
International organisations and funding agencies should insist that the countries they help must predominantly use national resources to develop and sustain their own national healthcare services.

 2. Cancer control needs a joined up approach

Another lesson we need to learn is that countries need to approach cancer control as a whole, linking prevention, early detection, treatment and palliative care. In Latin America, for instance, screening with the Pap smear was carried out for many many years, with very little impact on disease. Everyone blamed the poor cytology, but the bigger problem was that most women with the positive cytology never had a diagnosis made and never received treatment.

Governments and international agencies need to take a more comprehensive view across the entire spectrum of cancer control.

I think we have lessons to learn here from the comprehensive approach taken by the GAVI alliance, which has been very successful in terms of immunisation coverage and reducing child mortality. So another key message I would like to see coming out of the World Oncology Forum is:
We need to think in terms of a global alliance for cancer care continuum.

 Other key issues

Other key issues I will be asking the World Oncology Forum to consider include:

  • The urgent need to secure universal access to basic early diagnosis and treatment services
  • Opportunities for working within the wider efforts to tackle “non-communicable diseases”
  • Reversing the worrying trend towards adopting expensive and unnecessary imaging investigations, very expensive, very high-tech radiotherapy equipment and techniques, and expensive chemotherapy regimens and targeted drugs whose additional benefit has not been well demonstrated.

I look forward to the discussion

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