The affordability issue for cancer treatment has been the subject of a raging debate since quite some time, as the incidence of cancer is fast increasing across the world. Just for example a very recent report highlighted that cancer has now become the greatest health risk in the UK, with an average British boy born in 2010 running a 44 percent chance of being diagnosed with any form of cancer during his lifetime. The risk for a baby girl is slightly lower at 40 percent.
In India too, the problem of affordable cancer treatment has now become the center piece of a fiercer public opinion in the healthcare space, more than even HIV, prompting the Government to intervene in this dreadful disease area and address the problem in a holistic way both in the short and also on a longer term basis. This demand is supported by rapidly growing number of cancer patients in the country.
Out of the total number of new cancer patients globally, India now reportedly ranks third as follows:
| Rank | Country | % Of total |
| 1. | China | 22 |
| 2. | USA | 11 |
| 3. | India | 7.5 |
As a consequence, cancer now reportedly accounts for one of the main causes of deaths in India, which is nearly 19 percent higher than deaths caused by heart diseases.
Number of new cancer patients staggering in India:
Over 60,000 new cases are reportedly diagnosed every year in India and 80 percent of them are at an advanced stage, which involve mostly the middle-aged and elderly population of the country, where affordability is even a greater issue.
Cervical and breast cancers are reportedly the most common, contributing over 26 per cent to the total cancer cases in India, followed by lung, mouth, pharynx, ovarian, pancreatic and esophagus cancers.
Whereas cervical cancer is reportedly most common in females with a mortality rate of nearly 15 per 10,000 females, lung cancer has the highest mortality rate of 28 per 10,000 males.
Incidentally, lung cancer is the most commonly diagnosed cancer even globally. Non-Small Cell Lung Cancer (NSCLC) accounts for approximately 90% of all lung cancers. The primary cause of lung cancer in up to 90% of patients is tobacco and represents one-fifth of all cancer-related deaths in India.
However, to address the havoc caused by this dreaded disease effectively, India will also need to bridge the huge gap of shortfall in disease diagnostic infrastructure in the country.
The humongous access gap for cancer patients needs to be effectively addressed by the Government sooner with Public-Private-Partnership (PPP) for diagnosis and treatment, in tandem with other proactive initiatives like, disease awareness campaigns targeted to ensure greater screening and disease prevention, wherever possible.
‘The Lancet’ finding:
Following are some of the important findings on cancer disease profile in India, as reported in May 12, 2012, edition of ‘The Lancet’:
- 6 percent of the study deaths were due to cancer
- 71 percent cancer deaths occurred in people aged 30—69 years
- Age-standardized cancer mortality rates per 100,000 were similar in rural and urban areas but varied greatly between the states, and were two times higher in the least educated than in the most educated adults.
This report further calls for immediate Government intervention in this area.
Growing patients number making ‘Oncology Market’ increasingly attractive:
As stated above, incidence of various types of cancer is rapidly increasing across the world, making oncology segment an ‘El Dorado’ for many pharmaceutical players prompting commensurate investments for product development in this area, be these are new molecules or biosimilars.
Thus, the global turnover of anti-cancer drugs, which was around US$ 50 billion in 2009, is expected to grow to US$ 75 billion in 2013 registering a jaw dropping growth rate in today’s turbulent global pharmaceutical market environment.
World Health Organization (WHO) has predicted over 20 million new cases of cancer in 2025 against 12 million in 2008.
Globally, the segment growth will mainly be driven by early detection, longer duration of treatment and the global ascending trend in the incidence and prevalence of cancer propelled by new treatments and improved access to cancer therapies in many countries.
Indian business landscape:
Oncology segment has now emerged as a leading therapeutic area in the Indian pharmaceuticals market too, being fourth largest in volume and tenth largest in value term, mainly driven by lower priced generic equivalents in volume term.
Despite only a smaller number of patients can afford any comprehensive cancer treatment protocol in India, the demand for cancer drugs in the country, where many drug companies follow various types of unconventional logistics systems to reach these drugs to patients, is increasing at a rapid pace.
Global players namely, Roche, BMS, Pfizer, Sanofi, GSK and Merck reportedly dominate the market with innovative drugs. Whereas, domestic companies like, Natco Pharma, Cipla, Sun Pharma, Dr. Reddy’s Lab (DRL), Biocon and others are now coming up with low price generic equivalents of many cancer drugs.
The fact that currently over 30 pharmaceutical companies market cancer drug in the country, demonstrates growing attractiveness of the Oncology segment in India.
Access to newer cancer drugs:
It has been widely reported that newer cancer therapies have significant advantages over available generic cancer drugs both in terms of survival rate and toxicity.
Unfortunately such types of drugs cost very high, severely limiting access to their therapeutic benefits for majority of patients. For a month’s treatment such drugs reportedly cost on an average US$ 3,000 – 4,500 or Rs 1.64 – 2.45 lakh to each patient in India.
More R&D investments in Oncology segment:
Another study recently published by ‘Citeline’ in its ‘Pharma R&D Annual Review 2012’ points out, more than half of the top 25 disease areas targeted for R&D falls under cancer therapy. Breast cancer comes out as the single most targeted disease followed by Type 2 diabetes.
This will ensure steady growth of the Oncology segment over a long period of time and simultaneously the issue of access to these medicines to a large number of patients, if the product pricing does not fall in line with socioeconomic considerations of India.
Cancer drug sales dominated in 2012:
It is interesting to note that around one-third of the ‘Top 10 Brands in 2012′ were for the treatment of cancer as follows:
Top 10 global brands in 2012
| Rank | Brand | Therapy Area | Company | Sales: (US$ bn) |
| 1. | Humira | Rheumatoid Arthritis and others | Abbott /Eisai (now AbbVie/Eisai) | 9.48 |
| 2. | Enbrel | Anti-inflammatory | Amgen/Pfizer/Takeda | 8.37 |
| 3. | Advair/Seretide | Asthma, COPD | GlaxoSmithKline | 8.0 |
| 4. | Remicade | Auto-immune | Johnson & Johnson/Merck/ Mitsubishi Tanabe | 7.67 |
| 5. | Rituxan | Anti-cancer | Roche | 6.94 |
| 6. | Crestor | Anti-lipid | AstraZeneca/ Shionogi | 6.65 |
| 7. | Lantus | Anti-diabetic | Sanofi | 6.12 |
| 8. | Herceptin | Anti-cancer | Roche | 6.08 |
| 9. | Avastin | Anti-cancer | Roche | 5.98 |
| 10. | Lipitor | Anti-lipid | Pfizer/Astellas Pharma/Jeil Pharmaceutical | 5.55 |
(Source: Fierce Pharma)
Responsible Pricing a key issue with cancer drugs:
In the battle against the much dreaded disease cancer, the newer innovative drugs being quite expensive, even in the developed markets the healthcare providers are feeling the heat of cost pressure of such medications, which in turn could adversely impact the treatment decisions for the patients.
Thus, to help the oncologists to appropriately discuss the treatment cost of anti-cancer drugs with the patients, the ‘American Society of Clinical Oncology’ recently has formed a task force who will also try to resolve this critical issue.
In many other developed markets of the world, for expensive cancer medications, the patients are required to bear the high cost of co-payment. This may run equivalent to thousands of U.S dollars, which many patients reportedly find difficult to arrange.
It has been reported that even the ‘National Institute of Health and Clinical Excellence (NICE), UK’ considers some anti-cancer drugs not cost-effective enough for inclusion in the NHS formulary, sparking another set of raging debate.
‘The New England Journal of Medicine’ in one of its recent articles with detail analysis, also expressed its concern over sharp increase in the price of anti-cancer medications, specifically.
An interesting approach:
Experts are now deliberating upon the possibility of creating a ‘comparative effectiveness center’ for anti-cancer drugs. This center will be entrusted with the responsibility to find out the most cost effective and best suited anti-cancer drugs that will be suitable for a particular patient, eliminating possibility of any wasteful expenses with the new drugs just for newness and some additional features. If several drugs are found to be working equally well on the same patient, most cost effective medication will be recommended to the particular individual.
India should also explore this possibility without further delay.
Indian Government trying to find an answer in CL/NLEM/NPPP 2012:
Going by the recent developments in Compulsory License (CL) area for high priced new and innovative cancer drugs, it appears that in the times to come exorbitant prices for cancer drugs may prove to be loaded with risks of grant of CL in India due to immense public pressure.
It appears from the grapevine that Government may also explore the possibility to include some of the newer cancer drugs under National List of Essential Medicines (NLEM) bringing them under price control in conformance with the National Pharmaceutical Pricing Policy 2012 (NPPP 2012), if not through the provision of pricing of patented drugs.
Thus responsible pricing of cancer drugs assumes huge importance for avoidance of the above unpleasant situation in India.
Cancer drug pricing related developments in India:
As stated above, cancer being the second largest killer in India and the patented cancer drugs being generally expensive, a large Indian pharmaceutical player has been reportedly insisting on the government to allow widespread use of “compulsory licenses” for cancer drugs. About 11 years ago various news reports highlighted that this company broke ‘monopoly ‘ of the multinationals by offering to supply life-saving triple therapy AIDS drug cocktails for under US$1 a day, which is about one-thirtieth the price of the global companies.
In May 2012, this same Indian company named Cipla, significantly reduced the cost of three medicines to fight brain, kidney and lung cancers in India, making these drugs around four times cheaper than the originators, as per the above news report. The company reportedly wants to reduce the prices of more cancer drugs in future.
Prompted by the above steps taken by Dr. Yusuf Hamied, the Chairman of Cipla, many global players have reportedly branded him as an Intellectual Property (IP) thief, while Dr. Hamied reportedly accused them of being “Global Serial Killers” whose high prices are costing many precious lives across the globe.
In the same interview Dr. Hamied said poverty-racked India “can’t afford to divide people into those who can afford life-saving drugs and those who can’t”.
Promising future potential for low cost newer generic cancer drugs:
While R&D initiatives are going on full throttle for newer and innovative drugs for cancer, interestingly over a quarter of the following 15 brands, which will go off-patent in 2013 are for cancer, throwing open the door for cheaper newer generics entry and increasing access to these medicine for a larger population of cancer patients.
Patent expiry in 2013
| Rank | Brand | Generic name | Therapy Area | Company | Patent Expiry | Sales US$ billion (2012) |
| 1. | Cymbalta | Duloxetine | Antidepressant, musculoskeletal pain | Eli Lilly/Shionogi | Dec 11 | 4.9 |
| 2. | Avonex | Interferon beta1a | Multiple Sclerosis (MS) | Biogen Idec | Dec 31 | 2.9 |
| 3. | Humalog | Insulin lispro | Anti-diabetic | Eli Lilly | May 7 | 2,52 |
| 4. | OxyContin | Oxycodone | Pain | Perdue | August 31, | 2.35 |
| 5. | Rebif | Interferon beta-1a | Multiple Sclerosis (MS) | Merck KgaA | Dec 31 | 2.3 |
| 6. | Aciphex | Rabeprazole | Acid-peptic disorder | J&J, Eisai | May 8 | 1.93 |
| 7. | Xeloda | Capecitabin | Cancer | Roche | Dec 14 | 1.63 |
| 8. | Procrit | Epoetin Alfa | Anemia | J&J | Aug 29 | 1.41 |
| 9. | Neupogen | Filgrastim | Cancer | Amgen, Kirin, Roche, Royalty Pharma | Dec 12 | 1.29 |
| 10. | Zometa | Zoledronic Acid | Cancer | Novartis | March 2 | 1.26 |
| 11. | Lidoderm | Lidocaine patch 5% | Pain-relieving patch | Endo Health Solutions/ EpiCept | Sep 15 | 0.918 |
| 12. | Temodar | Temozolomide | Cancer | Merck, Bayer | Aug 31 | 0.882 |
| 13. | Asacol | Mesalamine | Ulcerative Colitis | Warner Chilcott, UCB, Zeria Pharma | Jul 30 | 0.891 |
| 14. | Niaspan | Niacin | Anti-lipid | Abbott, Teva | Sep 20 | 0.835 |
| 15 | Reclast | Zoledronic acid injection | Osteoporosis | Novartis | March 02 | 0.612 |
(Source: Fierce Pharma)
A thought:
Initiatives for faster resolution of a pressing issue like providing affordable treatment for cancer should not be put in the back burner of a longer term planning process. The issue is very real, humanitarian, here and now, for all of us. The Government is expected to display some sense of urgency through its expeditious intervention in all the four of the following treatment processes for cancer to make them affordable, if not free for the general population:
- Medical intervention and consultation
- Diagnostic tests and detection
- Surgical procedure and hospitalization
- Medicines and chemotherapy
As ‘The Lancet” study mentions, cancer in India is all-pervasive. It has no rich or poor, urban or rural or even any gender bias. It needs to be addressed in a holistic way for the benefit of all.
Conclusion:
High incidence of cancer in India with even higher mortality rate, coupled with very high treatment cost has positioned this disease area in the eye of a stormy debate for quite some time. The naked fact that a large number of Indian population cannot afford the high treatment cost for cancer as ‘Out of Pocket’ expenditure, has made the issue even more sensitive and socially relevant in India.
Pricing issue for cancer drugs is not just India centric. Even in the developed countries, heated debate on expensive new drugs, especially, in the oncology segment is brewing up for a while. This could possibly assume a much larger proportion in not too distant future.
It is about time for also the private players to come forward and extend support to the Government in a joint endeavor to tame the destructibility and catastrophic effect of this dreaded disease on human lives, families and the society in general. Setting access improving tangible examples through Public Private Partnership (PPP) initiatives, rather than mere pontification of any kind, is the need of the hour.
If it does not happen, soon enough, willy-nilly the concerned players in this area may get caught in a much fiercer debate, possibly with a force multiplier effect, inviting more desperate measures by the Government.
Responsible pricing, for the patients’ sake, of each element of the cancer treatment process will ultimately assume a critical importance, not just for survival and progress of any business, but also to fetch pots of gold, as business return, from the ‘El Dorado’ of ‘Oncology Segment’ of India.
By: Tapan J. Ray
Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.