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Global Realities of ASCO Innovation: Perspectives From The UK
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Released: July 15, 2025

John Marshall
John Marshall, MD
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Global Realities of ASCO Innovation: Perspectives From The UK, Latin America, and Eastern Europe

 

John Marshall, MD: Hey everybody. John Marshall for Oncology Unscripted sort of still on ASCO, not letting go of that, and this little bitty series is about I Access to treatments around the world. We all go to Chicago or to ESMO this year in Berlin, and we see new big productions, new data, expensive medicines, but medicines that are having major impact.

 

And here in the United States we have this sort of perspective that we can have whatever we want. And for the most part, we are the primary market for a lot of these new cancer drugs. And we've talked about that before, but I thought. Post-ASCO. It's really, really important for all of us to pause and think a little bit about rest of world because we don't have the same access around the world.

 

INTERVIEW WITH DR DAVID KERR

 

And to help me discuss this is an incredible leader in the world of oncology today. And also, I am lucky enough to call him my friend and have spent some time with him and his family in that beautiful spot over his shoulder there in Oxford, and this is professor Dr. David Kerr, who is down from Scotland, in his current, place of, Oxford. and he's been willing to join us. So David, welcome to Oncology Unscripted. Give the fans here a little bit, background about you, and then maybe just jump right in in terms of access and how you folks there in the public health service figure that out.

 

David Kerr, CBE, FMedSci, FRCP: Great to see you, John, and of course, welcome to you and the rest of the gang from the dreaming spars of Oxford, which you can see over my shoulder. so I'm David Care Professor of Cancer Medicine at University of Oxford. I, sidekick friend of John for more years than either of us would care to account and probably have lost the sort of distant tracks of time for former president of esmo.

 

I chaired the ASCO International Committee for a while. Fantastic outfit, and I've just been elected to the board of the UICC, which gives quite an interesting overview globally. About inequity, the, the unfairness, the lack of reasonable distribution of access to. medicines in the uk. many years ago, I served as a health advisor to then Prime Minister Tony Blair, we set up something called nice. This was a National Institute for Clinical Excellence and effectively. a rational means of drug rationing. that's not oxymoron. We can put that into the same sentence. And what it does is it looks at the data.

 

What are the clinical benefits of it?  How much does that cost? And in the context of a socialized healthcare system, such as our NHS, how does it stack up against hip replacements against vaccinations for children, against smoking prevention programs and so on. The whole gamut of cancer control, but, but placed within the wider context of all of medicine and, and poses a question, can we afford it?

 

Are the benefits sufficient for us to recommend that all the patients in NHS can get access to it? at one level, I think it's fear and transparent. And it's not a deal done in smoke-filled rooms. The old days was a machinery, a, logic, a statistical approach. All of us could understand, of course it's frustrating because quite often the answer can be no.

 

We come back from, ASCO, full of the joys of spring, full of the joys of early summer. and of course, medical oncologists wanting to do their very best for the patients that we look after, but frustrated by nice often saying no. And by the time taken, to be honest, it can take months, if not years, for the process to to go through. So, while the gold standard has moved ahead in the United States. But we find ourselves in stages, waiting to see if it can be done or afforded. And there's a frustration in that, as you would imagine.

 

John Marshall, MD: Let me drill down on some of this because, I've been always impressed by your work and the creation of the NICE committee. First, the transparency. As you say, you publish the analysis in Lancet Oncology of, of a yes or a no. Is that right? And, and the committee is a formal charge on behalf of the nation, if you will, instead of me dealing with the Blue Cross physician. You all are taking the responsibility on the backs of, on, on behalf of your country. Is that, is that the way it works?

 

David Kerr, CBE, FMedSci, FRCP: It, it, it is, it's a national committee. So, when, when the, the reason that we kicked this off all those years ago with the Blair government, we had a thing called postcode prescribing. So even with NHS there was significant variation. Variation is a word that we might come back to 'cause that makes us nervous. 'cause variation is usually, it's usually leveling down rather than leveling up the NHS was set up, different regions, different districts. you're living in a, a village in England, if, if one side of the village road happened to be in District X rather than District Y, you know, your neighbors might get the drug, but you wouldn't. It was extraordinarily ridiculous. So, we created this national body exactly as you said. That we take a decision on behalf of all the citizens of the United Kingdom.

 

John Marshall, MD: The other piece that, or a second piece that I wanted to focus on is this, this concept of you take something away, if you're gonna bring a new thing in, if you're gonna bring a new product in, you're, you're trading off something, or on the other side, making some recommendation to raise taxes. Is that true or is that my version of it?

 

David Kerr, CBE, FMedSci, FRCP: No, so, so you, you've opened up to a philosophical canof worms. One is we're a taxation-based health service therefore, like Moby Dick, it's the ever-open mo that we are a sort of endless money pit. To, to use a sort of term from Hollywood and so on. So, we just go on and on consuming and using, and successive governments health secretaries talk about the form of NHS, improving efficiencies and so on. But this is an organization with 1.35 million employees. I think we're the fourth largest outfit in the world after the Chinese People's Liberation Army, the Indian Civil Service. Then probably is actually, so you can imagine managing that outfit is horrendously complex and we have disconnected hierarchies.

 

The boss, the health secretary says I've made the decision and he thinks that that will sprinkle down throughout the NHS far, far, far from it. But other thing that you, that, the other thing that fascinates me is the concept of value in the headroom. So, so you're exactly right. If, if I had the. If I hit the national cancer budget under my control, then I wanted to bring innovative. Worthwhile new drugs coming through you, you and I would recognize these, so we're not talking about an improvement in disease-free survival of six weeks, but we're talking about impactful real drugs that make a difference. Exactly. So, we, we make a secret sign But in order to bring that in, how do we create the headroom? Well, by not doing stuff that's useless, should we be giving 10th line breast cancer chemotherapy? I, I dunno why I particularly said that, but you get the point, way beyond the evidence base using I I don't mean this to sound horrible using chemotherapy as an emotional, psychological crutch for me as well as for my patients. It's, it's, it's a trap that we mustn't fall into and those of us older, wiser, I think, often manage to avoid it. But for young colleagues who want to do the best they can to leave no stone unturned, we give quite a lot of actually, ultimately treatment. I'm sorry to say.

 

John Marshall, MD: I think you're totally spot on.. One thing that sort of came to me, this ASCO. As we talk about the cost of precision medicine, doing the tests, let's just start there. Or could be MRD testing, ctDNA testing, identifying those people still at risk, et cetera, instead of just treating everybody and crossing your fingers you know, how do we identify value to your word? And I like this word. It's like when I see someone presenting a new study at the plenary session, the slide that's missing. Is the value slide. So, if I do a test and it identifies the 9% of BRAF patients in colon cancer and my survival delta is big, what we're not showing and the cost of that, let's be fair.

 

The added cost of both the test and the new drugs, your, to your point, what we are not showing is the useless medicines that we are not giving. And so, on some level, we've made ourselves. More efficient, it becomes worth it because then we don't give the therapies that don't have the value. So, I, it's always about adding on instead of what is it taking away when we make progress.

 

You think that's right?

 

David Kerr, CBE, FMedSci, FRCP: Isn't value an interesting word and it's a double-edged sword. So, all of us want to get value for money. We're buying a new car, we're doing this, we're doing that. You know, the value are usually where you get cheat cuts of meat. It's usually of inferior quality. And so somehow wrongly value can be associated with a poorer effort. A poorer outcome, and a a, so I'm going to plug like crazy, A wee book that's Grain I wrote called how to get better value healthcare, the focus on cancer, and this is trading in some fantastic work coming out of Harvard. And how do we define value? And we defined it in terms of what the inputs are exactly as you said, what all the various costs and elements are, and so what the outputs are, what, what we achieve in some way. And so, it's moving just beyond the health economics of it. I agree with you. That's one element of it, but not, not the most important of it, too sharply focused on, you know, the impact of the new drug and the new test without taking account of the wider picture.

 

John Marshall, MD: Let's go to one other area, and this is just the, the cost and the negotiation process. So here in the United States under there’s a law that says we are unallowed to judge value. That whatever the industry asks for, the product we are on, government and Medicare, et cetera, is going to pay that and that markup. Again, our secret sign, that big markup is what is going back into drug development or global drug development. That's part of the budget that these multinational companies have, and since the last administration we have that's been challenged, and so everyone's very anxious that we won't have that money for reinvestment. I also see on your side. A different level of negotiation is that, you know, if, if, if, if you charged, you know, one of the big companies this amount, you could fit in under our budget. Right? So, you are getting a different price hopefully for takes too long. I granted, but you're getting a different price at the end of the day than we are. So on some level, when we talk about the imbalance or the inequity, I think the American public needs to recognize that we, and it's our taxes and other things coming out of our paychecks are paying more for a given thing than you guys are able to negotiate as a collective. And, you know, so I, the individual versus the collective.

 

What, what are your thoughts about that?

 

David Kerr, CBE, FMedSci, FRCP: I think if it wasn't for US drug market, with all the elements that you said, I'm sure that there wouldn't remotely be the same drug development expertise going on in the world. the idea about that imbalance being redressed in some way, be fascinating to see how, how your administration will deal with it. Our civil servants are negotiating behalf of the whole, of the, a whole country, you know, 65 million people, so they'd hope to be able to get a good deal. clearly your administration have spotted the huge differential in prices comparing many, if not all European nation states with the, the prices going on. United States, it doesn't seem fair, and I've said that I've benefited from your large s scientific and tax dollars for the past 40 years. I, I, I'd be very honest about it.

 

John Marshall, MD: I always wonder about the other side of this argument is that only, I think the figure is somewhere around one in seven people on our planet has access to cancer care at this level. And so, I, my sort of running joke about this is that we're selling Lexuses when in fact we could be selling Toyotas and selling it to more people.

 

And I've never really understood to this. What feels like false economy, and we are in the middle of it of course, because we are counseling and consulting with the industry people. We are providing care. You on a national level, coaching, you know, your country on how best to do this. It would seem like there should be some opportunity here to sell to more individuals and therefore make up the difference in that way and solve.

 

One of the problems that you and I recognize all along is that so many people just simply don't have access.

 

David Kerr, CBE, FMedSci, FRCP: If only we knew more about economics of, you know, sell low, something like that, which is.

 

John Marshall, MD: Behind you, they teach that, don't they?

 

David Kerr, CBE, FMedSci, FRCP: No, you're right. There are a couple of Nobel Laureates their people, the Fields Medal. So, there are some bunch of smart people, but they, they, God, you know, they do their own thing.

 

So, the UICC. great organization is a multi-member institution. It's a union, international control of cancer. We've got a brilliant program called Atom, working with pharma to make expensive drugs available in low-income countries. And I, I think both you and I would agree that the perfect as enemy of the good, rather than saying that every citizen on earth deserves a gold standard Cruiser, deluxe, NCCN ASCO and ESMO guideline driven cancer treatment. That's that, that cannot be the deal. It just cannot. And I was my president, I was very keen to see what we could do to establish. Functional, sensible guidelines that took account of individual countries could afford. And I would rather that we gave something that was decent but not perfect rather than nothing at all and had all sorts of interesting ideas.

 

But I ran into a few problems. It was fascinating and that some of my colleagues from low-income countries said that. I was trying to, how did they put it? Quite strong language. I was imposing an imperial, Imperial approach to saying, I'm denying people from income countries perfect treatment.

 

I said, I'm not, I'm being utilitarian. Let's treat more people pretty effectively rather than. people very effectively 'cause that that was a price differential, low dose metronomic, oral chemotherapy for breast. Why not? It's not, it's not like humdinger. This would do some good for the masses. Vast majority of people. I'm getting about it, but no, I mean, you've hit upon something that. that bugs me. and, and we need to find a better way of doing it. And I think we are the WHO Essential Medicines list, with work that's going on to reorient the guidelines and, and to make them more cost sensitive and to work with colleagues to say, let's reach out to wider segment of our population, moderately effectively, run a tiny sector with cruiser, deluxe drugs. it's a hobby horse, as you can tell.

 

John Marshall, MD: I could go on for a while, which is why I think they created pubs in your beautiful land. and maybe next time we are together, we should do that. But for now, let us, Call it an evening. thank you one more time for taking your valuable time away to share with our audience actually on a pretty global audience nowadays with electronics and all of that, our reflections and discussion around, the impact of innovation and how do we distribute that innovation to more people. Professor, Dr. David Ker. Thank you very much for joining us on Oncology Unscripted.

 

Good to see you, John, and delighted to take part.