Global Perspectives on Access to Cancer Care: Interviews With Drs. Carlos Barrios, Stefan Pörsök, and David Kerr

[00:18:06] John Marshall, MD: John Marshall, Oncology Unscripted. Different background, different location. I’m actually being a dad this weekend. I’m helping my daughter move from where she just finished schooling down I-95 away to her first job and her next apartment. So, we’re all excited, but I can’t help but remind us all about what Oncology Unscripted is all about.

It is about giving us information that we can go out there and not only practice day-to-day and influence our world, our cancer world, and our research world day-to-day, but also have an influence of future policy that’s out there. And we decided, maybe because it’s summer, maybe because it’s a year later and not enough has changed, to bring to you an encore presentation of some interviews that we did from global experts from around the world, really focusing on this concept of access.

It is a year later. We have new drugs, very cool new products, new trials demonstrating positive results, but still, most of the people around the world don’t have access to those things we have here in the United States. So, we thought here at Oncology Unscripted that it was worth bringing forward some of those highlights in an encore presentation. So, stick here and listen in.

We are now in wintertime in South America and being joined by Dr Carlos Barrios, who’s been kind enough to join us and give, if you will, a south-of-the-equator perspective. When you see expensive, fancy therapies, a fancy blood test, what’s that like? Can you apply those things right away to your practice there in Brazil, or are those things that take time for you to have access to?

[00:19:57] Carlos Barrios, MD: I think that is very, very important and critical for everybody to recognize that it’s one of the most important, if not the most important, discrepancy, universal discrepancy, at the present time. People may not be aware of this, but pharmaceutical industries in general have the United States as the main market. If a new drug gets into the market, of what is consumed of that drug, it’s 65% in the United States, about 20% to 22% in the 5 main countries in Western Europe, and 7% in Japan. So, if you add what actually sells new drugs into the market in the first 5 years, it ends up being 90% in those 3 or 4 markets.

That leaves only 10% for the rest of the world.

John Marshall, MD: And we’re talking about, you know, what is that, 6 billion people? I always say that it—

Carlos Barrios, MD: Seven billion people currently in the world.

John Marshall, MD: Yeah.

Carlos Barrios, MD: And only 1 billion actually have some kind of access at the present time.

John Marshall, MD: Yeah, and this is the statistic I use, that only 1 in 7 of us on the planet has access to that kind of cancer care. And so, give me a little sense about how did we move on from that? I mean, there is a lot of turmoil going on right now in the United States, as you know, around health care. Who should get it? Your country has struggled over time. Where does it stand right now in your country, and what would you advise if you were in the White House right now?

Carlos Barrios, MD: You are asking a very, very difficult question that doesn’t have an answer. If there is an answer to this situation, probably we would have already found a way to solve this because it’s very, very difficult to live with this kind of discrepancy.

In Brazil, for example—and then I try to address your question specifically—but just to tell you, in Brazil as an example, 80% of the population does not have any access to any of the new advances. Only 20% of the population actually does. So, it’s not a small problem. Okay?

So, you ask me for a solution, and obviously it doesn’t have one kind of solution, but I have some ideas in this regard. The first step in my idea is that we need to put everybody together. Governments need to be there. The societies need to be there. Patients need to be there. Society overall needs to be there. Pharmaceutical industries need to be there. Okay?

And I think the main problem in my view is that pharmaceutical industries actually price their drugs. Okay? And that’s another very big discussion, how drug pricing is actually done. But they price the drug for the main market. So, whatever the United States can pay, they decide on the price. The United States, according to what I know, doesn’t negotiate prices with the pharmaceutical vendors, so they can put whatever price they want. Okay? So, my main solution at the present time that would change immediately this situation would be for the United States to start negotiating prices with the pharmaceutical industry because if you drop the price in the United States, you are gonna be making access possible to a number of different places in the world.

John Marshall, MD: And to me, the point is exactly as you’re taking it. Then the solution is easy, that you then start selling at a lower price, but to many, many more people. And so—

Carlos Barrios, MD: Absolutely. So, the point is that we need to identify. It is like we do every single day. We have to make a correct diagnosis and try to interfere with the process in a very direct and practical way. And, in my opinion, that’s the single most important measure that can happen. It is not the only one, but certainly it’s the single most important measure that actually can make access much more prevalent all over the world for all these drugs.

One thing that I ask for governments everywhere—doesn’t necessarily need to be the United States—but in this kind of situation, do not want the government to give me the answer or give me the solution. I just want the leadership to be strong enough to put all the players together, everybody into a room, and lock the door and tell them, “I will let you leave once you give me a plan, a strategy, a solution,” because that leadership is absolutely essential for these things to move on and, hopefully, improve the lives of people all over the world.

John Marshall, MD: Carlos Barrios, thank you so much for taking time out of a busy day. I hope one day that your wish comes true and that we all find ourselves in that big room together, with the door locked, until we solve the problem.

Carlos Barrios, MD: I hope that that happens, and I would encourage you in the US to push for that important process because I think that’s one single thing that actually can have a consequence all over the world.

John Marshall, MD: I am so excited to be joined today by a very, very good friend and colleague. I’ve gotten to spend time in his hospital, in his hometown, and we just got back having run into each other in Chicago at ASCO. And part of what we started talking about while we were there was differences in access to cancer care.

Stefan Pörsök, MD, PhD: I don’t know this problem in other countries, but in our country we have difficulties with accessibility of targeted drugs. In colorectal cancer, mainly we have a problem with IO with MSI-high colon cancer or colorectal cancer. We are speaking or talking about just in a metastatic cancer. Neoadjuvant treatment approaches are not possible currently. Sometimes in young patients, we do a good job with reimbursement and we have the drug for the patient, but that’s not for everyone. BRAF-mutated colorectal cancer is a serious problem with combination therapy in second line. We have now good and practice-changing data in first line. I don’t know what will be the situation in our country, this practice-changing data.

John Marshall, MD: Let me ask you something. So, the IO for MSI, for example, to me is shocking because those treatments are so effective compared to standard of care and other chemos, you would think that that would tip the balance on the cost things. Can I ask a different angle, though? One, really two follow-ups. One is, are patients aware that there are these drugs out there that they don’t have access to?

Stefan Pörsök, MD, PhD: No, the patients don’t have awareness of these drugs because we have some experiences with these drugs currently in our republic, routine accessibility for IO in metastatic malignant melanoma, non–small cell lung cancer, triple negative breast cancer, renal cell cancer in second line, and for MSI-high metastatic colorectal cancer. We are waiting now for the discussion and final decision of our government and policies.

John Marshall, MD: You could argue that MSI-high colon works better in that than all the other cancer drugs you listed. So, it is crazy, isn’t it?

Stefan Pörsök, MD, PhD: Crazy.

John Marshall, MD: You go to ASCO. You’re always there, and—

Stefan Pörsök, MD, PhD: Yeah.

John Marshall, MD: Learning and you’re sharing your experiences with others. How frustrating is that meeting for you?

Stefan Pörsök, MD, PhD: I’m very frustrated from this ASCO. We have 10-year follow-up data, IO therapy, colorectal and noncolorectal cancer. We have data, 47 patients alive after 10 years after treatment. And it is cured, these patients. And this is very frustrating, and it’s terrible for the patient.

John Marshall, MD: What would be your thought about how to even access for global cancer care? Yes, it’s very expensive.

Stefan Pörsök, MD, PhD: Yeah.

John Marshall, MD: What would you recommend to the world to make it better?

Stefan Pörsök, MD, PhD: It’s a very hard question. Tumor-agnostic tailored therapy. This therapy has a very high percent of curability or prolonged survival of this patient and a very acceptable toxicity profile.

John Marshall, MD: I was thinking the same thing, as we do so many things that are wasteful using standard medicines. They don’t work. Or, like in adjuvant therapy, most patients don’t really benefit from it or don’t really need it, but we give it to everybody, and that’s covered. And yet we’re holding back on these, yes, expensive, but much more effective medicines. If we had to trade off, I think I probably would, to your point.

Stefan Pörsök, MD, PhD: We have a really nice surgery, interventional radiologists, radiation oncologists, but we have problems with the targeted drugs. And I guess we are not alone in the world with this problem.

John Marshall, MD: Yeah, it’s a problem we have to solve because there are a lot of people out there who could be cured of their cancer, certainly have a major impact on overall outcome. And I actually think on the backside would help lower the cost of drug development and return on investment for these companies that are discovering new drugs. Dr Stefan Pörsök, a good friend of mine, a little bit on the other side of the world, was gracious enough to spend some of his busy time with us 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. To help me discuss this is an incredible leader in the world of oncology today, 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. 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: 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 an 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 health care 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 placed within the wider context of all of medicine, 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 fair 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 go through. So, while the gold standard has moved ahead in the States, 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 a yes or a no. Is that right? 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 behalf of your country and your countrymen. Is that the way it works?

David Kerr, CBE, FMedSci, FRCP: It is. It’s a national committee. So, 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 downwards. It’s usually leveling down rather than leveling up. The NHS was set up, different regions, different districts. You’re living in a village in England. If one side of the village road happened to be in District X rather than District Y, 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, or a second piece, that I wanted to focus on is 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 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: So, you’ve opened up two philosophical cans of worms. One is we’re a taxation-based health service, therefore, like Moby Dick, it’s the ever-open maw, that we are a sort of endless money pit, to use a sort of term from Hollywood and so on. So, we just go on and on consuming and using, and successive governments and health secretaries talk about reform 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 it’s actually us. 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 the other thing that fascinates me is the concept of value and the headroom. So, you’re exactly right. If I had the national cancer budget under my control, then I wanted to bring innovative, worthwhile new drugs coming through. You and I would recognize these, so we’re not talking about an improvement in disease-free survival of 6 weeks, but we’re talking about impactful, real drugs that make a difference. Exactly. So, 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.

John Marshall, MD: 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—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, 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. But if you go to Kmart—attention, Kmart shoppers—the value aisle is usually where you get cheap cuts of meat. It’s usually of inferior quality. And so, somehow wrongly, value can be associated with a poorer effort, a poorer outcome.

So, I’m going to plug like crazy a wee book that Gráinne and 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? 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 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 the most important of it. Too sharply focused on the impact of the new drug and the new test without taking account of the wider picture.

So, I’d love to explore value with you. We haven’t got time just now, but next time we have one, let’s really get into value, and we’ll get someone here to come along who will bamboozle you with his bizarre Scottish accent, but his grasp of public health and what value means.

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.

We really hope you enjoyed that encore presentation, those interviews with global experts who are doing their best with the resources they have for their cancer patients in their communities. We need to reflect, those of us in Western medicine, particularly in the United States, on all of the luxuries we do have between access of medicines, access of testing, et cetera, and making sure we use those to their fullest, recognizing the value that we are bringing.

John Marshall, Oncology Unscripted.