Cancer 2014: Why do we need a focus on value?

Dr Paul Cornes
Conflict of interest
 Salary received:
• United Kingdom National Health Service
 Honoraria received:
• Roche
• Janssen
• Sandoz
• Lilly
• European Generics Association
• Teva
• Hospira

Cancer 2014 - Why do we need
a focus on value?
Dr Paul Cornes,
Consultant Oncologist,
Bristol Haematology & Oncology Centre
Comparative Outcomes Group
 Strive not to be a success,
ESO Task Force Advisory Board on
Access to Innovative Treatment in
Europe
but rather to be of value
European School of Oncology
Piazza Indipendenza, 2
6500 Bellinzona - Switzerland
paul.cornes@yahoo.co.uk

Cancer 2014 - Why do we need
a focus on value?
 Strive not to be a success,

Value is so much more than money

I value my work with international colleagues
Comparative Outcomes
Group

There is a cost to cancer
Cancer causes the
highest economic loss
of all of the 15 leading
causes of death
worldwide
83 million years of
“healthy life” lost due
to death and disability
from cancer in 2008.
WHO: Cancer world's
top killer since 2010
The total economic
impact of premature
death and disability
from cancer
worldwide was $895
billion in 2008.
16.7 percent of all
'healthy' years lost in
the European Union
cancer has the most
devastating
economic impact of
any cause of death in
the world.
www.usatoday.com/news/health/2008-12-09-cancer_N.htm
http://www.cancer.org/acs/groups/content/@internationalaffairs/documents/document/acspc-026203.pdf

There is a cost to cancer
Cancer causes the
highest economic loss
of all of the 15 leading
causes of death
worldwide
83 million years of
WHO: Cancer world's
top killer since 2010
The total economic
impact of premature
death and disability
from cancer
worldwide was $895
billion in 2008.
16.7 percent of all
the European Union
cancer has the most
devastating
economic impact of
any cause of death in
the world.
Sorting out the funding for
cancer will be the model used
to manage other medical
conditions
www.usatoday.com/news/health/2008-12-09-cancer_N.htm
http://www.cancer.org/acs/groups/content/@internationalaffairs/documents/document/acspc-026203.pdf

There is a cost to cancer care
“Think about health spending
as not consumption but
investment”
David E. Bloom,
professor of economics and
demography at Harvard
http://www.bloomberg.com/news/2011-06-20/global-rise-in-cancer-cost-300-billion-in-2010-harvard-economist-says.html
File:David E. Bloom at the World Economic Forum Summit on the Global Agenda 2008.jpg

Good news for medicine
 Basic cancer science is paying back on its investment
 One medical paper a minute is added to the PubMed US National
Library of Medicine
MEDLINE Citation Counts by Year of Publication. Available at http://www.nlm.nih.gov/bsd/medline_cit_counts_yr_pub.html,
accessed 2012 Sept 11. Template:2010 - Impact factor of selected medical journals.jpg/credit

Good news for cancer treatment:
Cancer survival is improving
OECD data on the G7 countries
Aaron Carroll. How do we rate the quality of the US health care system – Disease Care. The Incidental Economist.
October 21, 2010 at 4:00 am. Accessed April 29, 2014

Cancer survival is improving
1971, 50% 1
year survival
2010, 50% 10
year survival
Median Survival of
Cancer in the UK has
risen from 1 to 10
years since 1971
Triggle N. Half of cancer sufferers 'live a decade or more'. BBC News April 29th, 2014. http://www.bbc.co.uk/news/health-
27194823. April 29th, 2014.

Good news for cancer treatment
 This investment in innovation means that novel targeted biologic
approaches now dominate drug development
 It is predicted that 2012 was probably the year where biologic
therapy use outnumbered cytotoxic treatments
Vaccines
Immunostimulants
Gene therapy
Supportive care
Novel approaches
Hormonals
Cytotoxics
Timbs O, Sikora K. Cancer in the year 2025. Cancer World. 2004(September-October):12-19.
http://www.cancerworld.org/pdf/7556_05_Grand%20Round_12_19.pdf

Innovation in cancer drugs
5 cancer
drugs
<1960
+ 2
more
1960s
+ 18
more
1970s
+ 14
more
1980s
+ 24
more
1990s
+ 23
more
2000s
+ 20
more in
only 3
years
2010-13
At this rate our decade will add 67
new cancer drugs by 2020 !
Cornes P. Pictogram created from data in - Savage P. Development and economic trends in cancer therapeutic drugs: Analysis of
modern and historical treatment costs compared to the contemporary GDP per capita. J Clin Oncol 32, 2014 (suppl; abstr e17535)

Good news for cancer treatment
Drugs in
development,
2010
900 drugs in
development
are for cancer
The costly war on cancer. The Economist. 2011 May 26. http://www.economist.com/node/18743951

Innovation - 1984
1984 Nobel Prize
for Medicine
awarded jointly
to Jerne, Köhler
and Milstein
"for the
discovery of the
principle for
production of
monoclonal
antibodies".
30 years later

30 years of Innovation:
1984 to 2014 Monoclonal antibody development
Head and Neck
Cancer
Breast Cancer
Bowel Cancer
Leukaemia
Lymphoma
Ovary cancer
Secondary bone
cancer
Melanoma skin cancer
http://en.wikipedia.org/wiki/File:Da_Vinci_Vitruve_Luc_Viatour.jpg
Macular Degeneration
Multiple sclerosis
Asthma
Heart disease
Transplant rejection
Inflammatory bowel
disease
Arthritis
30 years later
Psoriasis

Monoclonals in cancer - lymphoma
http://www.jnccn.org/content/8/Suppl_6/S-1/F3.large.jpg
 Rituximab
• Halves lymphoma relapse
• Prima trial reviewed at
http://www.medscape.com
/viewarticle/722470

Monoclonals in breast cancer
 Trastuzumab
• Halves the chance of
relapse
• Reduces death by 33%
Romond EH, et al. NEJM. 2005;353:1673-1684

71% reduction in disability in multiple sclerosis
Campath-H1 vs interferon
http://users.ox.ac.uk/~path0116/tig/new1/mstrialfig.jpg

Controlling rheumatoid arthritis
Thermal imaging of hand
and elbow joints before……
http://users.ox.ac.uk/~path0116/tig/new1/thefg.gif
..and after Mab therapy

halves hospitalizations, surgeries, and
procedures in fistulizing Crohn’s disease
Infliximab
Lichtenstein GR. Infliximab maintenance treatment reduces hospitalizations, surgeries, and procedures in fistulizing Crohn’s
disease. Gastroenterology,Volume 128, Issue 4 , Pages 862-869, April 2005. http://en.wikipedia.org/wiki/File:CD_colitis.jpg

Efalizumab for psoriasis
Sylvia Marecki & Peter Kirkpatrick. Efalizumab. Nature Reviews Drug Discovery 2004;3:473-474
http://www.epgpatientdirect.org/send_article.cfm/page/355/title/Biologicals

Medical MAbs to 2013
Therapeutic monoclonal antibodies approved or in review in the European Union or United States. Note: Information current as of 28
February, 2013http://www.antibodysociety.org/news/approved_mabs.php

Survival impact of some targeted therapies
data from Munoz, J.et al (2012) Targeted therapy in rare cancers—adopting the orphans Nat. Rev. Clin. Oncol. doi:10.1038/nrclinonc.2012.160. Table from The
Value of Medical Innovation. http://valueofinnovation.org/a-world-free-from-cancer/#ref3, Accessed April 29, 2014

The world is aging: life expectancy is increasing
in all countries
http://flowingdata.com/2011/10/13/life-expectancy-changes/
The average
life expectancy
in 2009 was 67
Relationship of cancer
incidence with age
Peak age for
cancer is 70-84
years

Bad news for cancer treatment
 There will be more cancer to
treat
 Expected rise in 20 years
– http://info.cancerresearchuk.org/ne
ws/archive/pressrelease/2011-10-
28-NHS-burden-as-cancer-cases-to-
jump-by-45-per-cent
– http://www.breakingnews.ie/archive
s/2006/0607/ireland/potentially-fatal-
cancer-cases-predicted-to-double-
by-2020-262312.html
– Ibrahim E, et al. Current and future
cancer burden in Saudi Arabia:
meeting the challenge. Hematol
Oncol Stem Cell Ther. 2008 Oct-
Dec;1(4):210-5
45% rise
UK
90% rise
Ireland
800 –
1000% rise
Saudi
Arabia
1 in 4
Malaysians
will get cancer
by age 75

Bad news for cancer treatment
 Innovative drug development is slow and
expensive
 From 5000 - 10000 compounds in pre-clinical trials:
• only 0.1% reach clinical trial stage
• of these, only 10-20% are finally approved
 It takes 15 years from the target discovery to the
market at 1.4 Billion Euro / drug
– Adams CP et al: Estimating the cost of new drug
development: Is it really 802 million dollars? Health Aff
(Millwood) 2006;25:420-428
– ABPI. Delivering value to the UK: the contribution of the
pharmaceutical industry to patients, the NHS and the
economy. Updated. http://www.abpi.org.uk/our-work/
library/industry/Pages/310114.aspx. Accessed May 12th,
2014

Public Understanding of Drug Values
 More than 1000 people were interviewed as
part of a 2012 survey commissioned by the
Association of the British Pharmaceutical
Industry (ABPI)
ABPI concerned over medicines misunderstandings. Pharma Times 3rd September 2012. http://www.pharmafield.co.uk/news/2012/08/ABPI-concerned-
over-medicines-misunderstandings. Accessed Sept 9, 2014.
The majority of
respondents
thought new
medicines cost
less than £10m to
research and
develop
Estimates 2014 are
greater than 1
Billion USD per
drug

Health economics - is not usually an
interesting topic

ASCO 2009 Meeting emphasis:
individualised care and cost-effectiveness
USA Medical insurance costs are rising faster than earnings and general inflation
Ward E. CA Cancer J, 2008;58:9-31

Cost of USA cancer care 1963 to 2004
Cancer treatment spending, in billions
US$
$1.3
$13.1
$27.5
$72.1

Medicaid expenditures ($ billions) for outpatient
prescription drugs
US$
In 2003, Medicaid spent $33.7 billion on drugs (19% of national
spending for drugs and more than 10% of the Medicaid budget)

Cancer has a cost
Elkin EB, Bach PB. Cancer's next frontier: addressing high and increasing costs. JAMA 2010;303:1086-1087.
Meropol NJ, Schrag D, Smith TJ, et al. American Society of Clinical Oncology guidance statement: the cost of cancer care. J Clin Oncol 2009;27:3868-3874.

Planning for the future: what will happen to
costs?
What is the driver for increased spending:
ageing populations or medical treatment?
USA Office of management and Budget. www.whitehouse.gov/omb
medical
treatment

The world spends more each year for cancer
treatment
 Global spend on oncology drugs: projected for 2010-12
Spend doubled in 4
years 2004-2008
Data: IMS

Confirmation in Europe: Cancer drugs budgets
are doubling each 4 years
 Costs of anticancer drugs,
France:
• 2004 = 474 Million Euros
• 2008 = 975 Million Euros
– Perrin S. Therapeutic decision
making in oncology. Hospital
Pharmacy Europe. 2010
(Sept/Oct);52:36-37
Spend doubled in 4
years 2004-2008

Timeline of novel cancer drug approval
Carin A Uyl-de Groot et al. The Economics of Improved Cancer Survival Rates: Better Outcomes, Higher Costs. Expert Rev
Pharmacoeconomics Outcomes Res. 2010;10(3):283-292

Association of novel drugs and cancer mortality
Carin A Uyl-de Groot et al. The Economics of Improved Cancer Survival Rates: Better Outcomes, Higher Costs. Expert Rev
Pharmacoeconomics Outcomes Res. 2010;10(3):283-292

Association of novel drugs and cancer mortality
 new medicines have
accounted for 50-60 percent
of the increase in cancer
survival rates since 1975.
– Lichtenberg Fr. The Expanding
Pharmaceutical Arsenal in the
War on Cancer. National
Bureau of Economic research
Working Paper No. 10328.
February 2004.

Cost of cancer drugs by year of approval
Limits on
Medicare's
ability to
control
rising
spending on
cancer
drugs
Bach P. N
Engl J Med
2009;
360:626-633
Cancer drug
costs rise 5x
faster than other
classes of
medicine
Bach P. NEJM. 2009 Feb 7

Cost of treatment for metastatic colon cancer
(Schrag D. NEJM. 2004;351:317-319)
Cost of standard therapy has risen from
$63 / 8 weeks to $30,675 / 8 weeks:
500-fold rise in a decade

Cost of treatment for metastatic colon cancer
(Schrag D. NEJM. 2004;351:317-319)
>30,000$ /
8 weeks
<100$ /
8 weeks
The Oncologist April 1, 2005 vol. 10 no. 4 250-261. http://theoncologist.alphamedpress.org/content/10/4/250/F2.large.jpg

Innovation is expensive
12 drugs were approved by the US
Food and Drug Administration
(FDA) for various cancer
indications in 2012
11 were priced above $100,000 per
year
Kaitlin KI. Deconstructing the drug development process: the new face of innovation. Clin Pharmacol & Therapeutics. 2013.
Doctors say cancer drug costs are too high. http://medicalxpress.com/news/2013-04-doctors-cancer-drug-high.html. Cited 21/06/2013

What are policy-makers trying to do?
Langreth R. Will Health Costs Bankrupt America?. Forbes. http://www.forbes.com/forbes/2011/0314/health-care-recession-expenditure-bankrupt-america.html. Callahan D.
Health care costs and medical technology. http://www.thehastingscenter.org/uploadedFiles/Publications/Briefing_Book/health%20care%20costs%20chapter.pdf. Accessed May
7th, 2014

What are policy-makers trying to do?
 Protect and improve the health of the population
 Assure access to medical care
 Achieve efficient use of health care resources

Money doesn’t always buy life
Life expectancy at birth and health spend
3 fold variation
WHO. The World Health Report 2000

Money doesn’t always buy health
 Relationship
between spend
and health is not
always clear
• Disability-adjusted
life expectancy
relative to health
expenditure per
capita in USD in
191 WHO member
states, 1999
• WHO. The World
Health Report
2000, p43
>10 fold variation
US Dollars

There is no evidence that spending more will
consistently improve health
Hussey PS et al. The
Association Between
Health Care Quality and
Cost: A. Ann Intern Med.
1 January
2013;158(1):27-34

There is no evidence that simple cuts will
consistently improve health

Cost constraints in cancer treatment:
What can nations do?

There is one certainty in medicine:
Rationing does occur:
by personal
ability to pay
by society’s
willingness to pay
USA - one in five
families used up all of
their savings paying for
cancer treatment
Cavallo J. The ASCO Post, February 15,
2011, Volume 2, Issue 3

Cost constraints in cancer treatment:
What can nations do?
Countries can set a budget for
communal spending
Countries can set cost-effectiveness
limits to
reimbursement for new
treatments
Lichtenberg FR. Despite steep costs, payments for new cancer drugs make economic sense. Nat Med. 2011 Mar;17(3):244.

What is a cancer treatment?
Athas W F et al. JNCI J Natl Cancer Inst 2000;92:269-271
Something that makes you live longer
Something that makes you live better
Hopefully something that does both!

Car Parks as treatment?
Athas W F et al. JNCI J Natl Cancer Inst 2000;92:269-271

Computer terminals as treatment?
 Investment in Information Technology is associated with better
outcomes
 Each 10% increase in Health Information technology to access
EBM in a hospital saved 15% fewer deaths and 16% fewer
complications per admission and cuts costs.
Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and
inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009 Jan 26;169(2):108-14

Education as treatment?
Role of patient education
 51% of women don’t complete
adjuvant hormone therapy for
breast cancer
• Increased risk in younger
women
Non-compliance reduces
survival by 9%
1.3 million women in the USA
are prescribed hormone therapy
for breast cancer
RFS Tamoxifen 5y vs control in
women <50y - EBCTG
1. Hershman DL. J Clin Oncol.. 2010; 28: 4120-4128. 2. http://onlinelibrary.wiley.com/doi/10.1002/cncr.25781/pdf 3. EBCTG
http://www.ctsu.ox.ac.uk/pressreleases/1998-05-16/fact-sheet 4. Ma AMT, American Journal of Surgery. 2008;196:500-504.

Supportive care as treatment?
 Spending to save:
 Randomised trial-targeted
treatment for
advanced NSCLC
• OS better with novel
therapy
• QOL better
• hazard ratio for death in
the standard care
group, 1.70; 95% CI,
1.14 to 2.54; P = 0.01
Early
supportive
care
Care when
symptoms
progress
“targeted treatment” was supportive care
Temel JS. N Engl J Med 2010;363:733-42.

Exercise as treatment?
 Reviewed 34 randomised
controlled trials of exercise
therapy
 22/34 (65%) focused on
patients with breast cancer
 10/34 (35%) on all types of
cancer
 Physical activity improved
• Quality of life
• Physicial function
• psychological outcomes

Access to healthcare is driven by affordability
 Sir Andrew Dillon,
chief executive of
the National Institute
for Health and Care
Excellence, said --
 “the NHS would
never be able to
afford every drug
capable of making a
difference to
patients.”
Ward A, Neville S. Drug cost watchdog chief calls for honesty with public. FT.com August 22, 2014 3:28
pm.http://www.ft.com/cms/s/0/c62145a6-2896-11e4-8bda-00144feabdc0.html#axzz3BQtnSrsu. Accessed Aug 25, 2014

European countries -
with formal cost-effectiveness approval
Adapted and modified from Zentner et al, 2005

European countries - with budget impact or
formal cost-effectiveness approval

European countries - with clinical effectiveness
approval

 Aim of healthcare
• To live longer
• To live better
 Aim of the health care systems
• to maximise health outcomes using available resources

Economic evaluation - methodology
 Simplistic model – apply cost constraints
on “expensive” drugs
 Fails because some treatments that are
initially expensive are highly effective and
save money elsewhere in the health
system
• e.g. by increasing cures
• or by saving money from other
healthcare budgets
 Fails because “cheap” high volume drugs
may be relatively ineffective

Economics for the uninitiated
Economics is not primarily about saving money
It is about using scarce resources as efficiently as possible
Economists never say “cheap”or “expensive” -
they say “cost-effective” or “not cost effective”
You know more economics than you think

You know more economics than you think
Economics or Οἰκονομία – is a Greek word
Oikos = “the household”
+ Nomos = “wise rules”
Economics - “wise rules for managing the household”
“Health economics” =
Wise rules for managing the hospital

The 2 “E”s of pharmacology:
efficacy, effectiveness,
Can it work? Efficacy
Does it work in reality? Effectiveness

The 3 “E”s of pharmaco-economics:
efficacy, effectiveness, efficiency
Can it work? Efficacy
Does it work in reality? Effectiveness
Is it worth doing
compared to other
things we could do with
the same money?
Cost-effectiveness
= Efficiency

Is it worth doing compared to other things we
could do with the same money?
A Pound can only be spent once
Once money has been spent on one thing – it is a lost
“opportunity” to spend it on something else
economists call this the “opportunity cost” of spending

Focus care to where it helps us live longer and
live better
“Estimates
suggest that as
much as $700
billion a year in
health care costs
do not improve
health outcomes.
They occur
because we pay for
more care rather
than better care”
 Peter Orszag, director of the White House Office of Management
and Budget, May 2009 interview with NPR.
– http://www.factsforhealthcare.com/whitepaper/HealthcareWaste.pdf

Some countries control costs better than others

The power of health economic thinking
 Assuming we worry about costs, and that some public funded health care
is essential: could we perform better?
 185 publicly-funded interventions in the United States cost about
$21.4 billion per year, for an estimated saving of 592 000 years of
life (considering only premature deaths prevented).
 Re-allocating those funds to the most cost-effective interventions
could save an additional 638 000 life years if all potential
beneficiaries were reached.
 Tengs TO. Dying too soon: how cost-effectiveness analysis can save lives. Irvine, California,
University of California, National Center for Policy Analysis, 1997 (Policy Report No. 204)

Focus care to where it helps us live longer and
live better
OECD estimates 3 years extra UK life
expectancy possible if we matched the
efficiency of the best health systems
Isabelle Joumard. IMF Conference 21 June, 2011. OECD NHS inefficiencyOECD report.
http://www.imf.org/external/np/seminars/eng/2011/paris/pdf/Joumard.pdf. Cited 3 July 2013

The Tragedy of the Commons
http://lpfw.org/agreement-protects-carrizo-plain-from-severe-overgrazing/. Cited 3 July 2003

Cancer –
Now the greatest loss of healthy life in the world
Global burden of cancer in 2008: a
systematic analysis of disability-adjusted
life-years in 12 world regions.
Economic loss is > 3 times greater
than the costs of TB, Malaria and
HIV combined
Data from Soerjomataram I, et al Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in 12 world regions. Lancet. 2012 Nov
24;380(9856):1840-50. Diagram from The Value of Medical Innovation. http://valueofinnovation.org/a-world-free-from-cancer/#ref3, Acsessed April 29, 2014

Middle income countries face a considerable
burden of cancer
Kanavos P et al. The role of funding and policies on innovation in cancer drug development. Report for the
European Cancer Research Managers Forum. LSE September 2009.

Middle income countries face a challenge
 More cancer and Less drugs
low and middle
income countries
account for 61%
of the world’s
burden of cancer,
yet only account
for 5% of anti-cancer
drug sales.
The International Network For Cancer Treatment and Research Statistics> http://www.inctr.org/about-inctr/statistics/.
Accessed Sept 29, 2014

worldwide map of healthcare expenditure in 2008,
according to World Health Organization (WHO).
Ref: worldwide map of healthcare expenditure in 2008, according to World Health Organization (WHO). URL:
http://www.ezega.com/news/NewsDetails.aspx?Page=news&NewsID=2059. Accessed Nov 20, 2014

Worldwide comparison of healthcare expenditure in
2010, according to the OECD.
Ranked
80th
country for
health
spending
WHO (2010)
Malaysia =
$645 ppp
per capita
OECD
spend
average
$3,268
ppp
Malaysia
performs
very well
with 1/5th
the spend
Malaysian success in
cost-effective care may
help guide 112 poorer
countries to improve
Inescapable truth: some treatments we cannot afford
Ref: OECD 2010 health data. WHO ranking;
http://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_%28PPP%29_per_capita. Accessed Nov 21, 2014

Worldwide comparison of healthcare.
 The UN Development
Programme has called
Malaysia a "model for other
developing countries".
 With a dual system in place
administering heavily
subsidised primary care to all
citizens and a private sector
delivering specialty services to
those who can afford it,
average life expectancy has
risen to 74 years.
 The Economist, April 2014
Ref How sustainable is Malaysian healthcare? The Economist, April 11th 2014. URL:
http://www.eiu.com/industry/article/1991716983/how-sustainable-is-malaysian-healthcare/2014-04-11#. Accessed Nov 6, 2014

Will future funding increases come from
taxation?
 Demographic and lifestyle shifts have steadily made Malaysia's
population older and less healthy.
 The proportion of people under 15 years of age fell from 32% in
2002 to 26.7% in 2012, while the percentage of those aged over
60 climbed from 6.5% to more than 8% during the period.
 Comparing 2002 to 2012: MoH data:
Hypertension
+43%
Diabetes
+88%
Obesity
+250%
This predicts a
significant
upward
pressure on
National
Health costs

Will future funding increases come from
taxation?
 Government subsidies covered 55% of total healthcare spending
in 2011, according to the World Health Organisation (WHO),
 In the budget for 2014, the administration allocated M$22.1bn
(US$6.9bn) to healthcare spending, out of total expenditure of
M$217bn,
• representing over 10% of total government spending.

Commercial drug development requires a return
on investment
 Bayer CEO Marjin Dekkers quoted at the December 3, 2013 FT
Event, regarding Indian compulsory license of Sorafenib - Nexavar
 “we did not develop this product for the Indian market, let's be
honest. I mean, you know, we developed this product for western
patients who can afford this product, quite honestly”
Ref - Claire Cassedy. Transcript of Bayer CEO Marjin Dekkers quote at the December 3, 2013 FT Event, regarding India compulsory license of Nexavar. Knowledge
Ecology International. February 7, 2014. http://keionline.org/node/1924. Accessed Oct 30, 2013. Bayer AG’s "Science For A Better Life" Symposium - How Scientists See
Future Research Trend. BNC. November 20, 2013. URL: http://www.bnc.bayer.com/bayer/bnci.nsf/id/How-Scientists-See-Future-Research-Trends. Accessed Oct 30, 2014

Fears for the future of medicine:
 The we cannot afford to introduce future treatments that
the public will be demanding
 That Government or health insurers will ration treatment
in a way that puts doctors and patients into conflict
 That doctors’ freedom to direct and prescribe will be
restricted by outside guidelines that individual doctors
and patients are powerless to influence
Physicians are not powerless in this –
there is much that we can do already
But this will need Physician leadership

The options for future health spending include
the following:
 Carry on spending at current rates – postpone
the inevitable decision to contain spending
 Carry on spending at current rates and improve
efficiency and productivity
• that is, buy extra time before confronting the
inevitable decision to contain spending
 Align health spending growth to general, long-term
growth in the economy as a whole
• with possible adjustments to devote a
modestly greater share of GDP to health care
as GDP grows.
Untenable in the
medium term
Viable possibly
medium term
Only long term
viable option if
the state is to
provide health
care from
general
taxation
Appleby J et al. Spending on health care - How much is enough? Kings Fund 2006. URL: http://www.kingsfund.org.uk/sites/files/kf/SpendingonHealthCare.pdf. Accessed
Nov 2, 2014

The Evolution of Medical Decision Making:
 Pre-EBM - Evidence Based Medicine
• Focus on a novel mechanism of
action?
 EBM - Evidence Based Medicine
• Focus on efficacy
 VBM - Value Based Medicine
• Focus on effectiveness and “value” to
stakeholders
EBM “Does this intervention make you live significantly longer or
live better?”
VBM “Is this worth doing compared with other things we could do
with the same resource?”
Huber B et al. Oncology Drug Development and Value-based Medicine. http://www.quintiles.com/library/white-papers/
oncology-drug-development-and-value-based-medicine.pdf. Accessed June 27, 2014

Classes of treatments to target for cost-effective
care
Ref: Sullivan R et al. Delivering affordable cancer care in high-income countries. Lancet Oncol 2011;12:933

Malaysia would not be alone in making value
decisions in healthcare
Now - more than half
of the largest US
physician societies
explicitly consider
costs in developing
their clinical
guidance documents
Which is a big change
from 2002 when such
decisions were rare
Schwartz JAT et al. Cost Consideration in the Clinical Guidance Documents of Physician Specialty Societies in the United States. JAMA Intern Med.
2013;173(12):1091-1097. Wallace JF. The limited incorporation of economic analyses in clinical practice guidelines. J Gen Intern Med. 2002 Mar;17(3):210-20.

Conclusions
 Not every medical problem has a scientific solution
 Catastrophic rises in the cost of treatment threaten health
DOI: http://dx.doi.org/10.1007/s11523-011-0196-3
services across the world
 Our current model for health care now demands a change in
human values or ideas of morality
• as there are insufficient “common” resources to continue on
our current path in cancer medicine

Conclusions
 A switch from Evidence Base Medicine to Value Based Medicine
in Oncology requires that we understand what “value” is
 We need the support of the stakeholders and payers in cancer
medicine to discover that value and drive this change
 Our patients, their families and the public need confidence that
our next reimbursement guidelines offer the most effective,
equitable and ethical plan for treatment
 We need to understand the issues involved to address those
concerns

Conclusions
 Economics is not primarily about rationing – it is about using
scarce resources as efficiently as possible
 Economics deals in more then money
• It is the science of “wise rules”
 There is little evidence that spending more will reliably improve
outcomes
• We have to learn to spend better

Economics – we need both innovation and value
to access better cancer treatment
Gottlieb Daimler Henry Ford

We understand that we
doctors should be and are
stewards of the larger
society as well as of the
patient in our examination
room
Dr. Lowell E. Schnipper,
chief of Hematology/Oncology Beth Israel Deaconess Medical Center
chairman of ASCO task force on value in cancer care
Pollack A. Cost of Treatment May Influence Doctors. New York Times 2014 April 17. Grateful nation: Lowell E. Schnipper, M.D.
http://www.gratefulnation.org/site/PageNavigator/evening_of_gratitude/Evening_of_gratitude_bios. Accessed June 5th, 2014

Conclusions

Despite the stresses - We have chosen to treat cancer
It has the greatest
GLOBAL impact of
any threat to life
But is that true for an
individual?

Risk of Life Span Shortening as a Consequence of
Occupation, Disease, or Various Other Conditions
Expected Days of Life Lost
2800
2100
2000
1600
1100
980
900
20
435
400
200
74
40
12
1
Radiation worker
Speed limit increase
from 55 to 65 mph
Service in Vietnam
All accidents
30 pounds overweight
Working as a coal
miner
1 pack of cigarettes a
day
Being unmarried
Heart disease
Being male rather
than female
Having Cancer

Risk of Life Span Shortening as a Consequence of
Occupation, Disease, or Various Other Conditions
Expected Days of Life
Lost
2800
2100
2000
1600
1100
980
900
20
435
400
200
74
40
12
1
Radiation worker
Speed limit increase
from 55 to 65 mph
5 of 6 years are lost to
something other than
cancer
16.7 percent of all
the European Union
Service in Vietnam
All accidents
30 pounds overweight
Working as a coal
miner
1 pack of cigarettes a
day
Being unmarried
Heart disease
Being male rather
than female
Having Cancer
83 million years of

Albert Einstein
Strive not to be a success,

Cancer 2014: Why do we need a focus on value?

Cancer 2014: Why do we need a focus on value?

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Cancer 2014: Why do we need a focus on value?