In the countries that form the Association of South East Asian Nations (ASEAN), cancer is a rapidly growing disease. As with everywhere else around the globe, the impact and burden of cancer in ASEAN are on the rise, alongside steadily aging societies, urbanization and lifestyle changes. According to GLOBOCAN 2018, there were 18 million new cancer cases reported globally in 2018. Nearly half of them are estimated to occur in Asia . About 1 million of them were in ASEAN countries. Among the common cancers diagnosed in ASEAN are breast, lung, liver, colorectal and cervical cancers, which affect majority of middle-aged people in the prime of their working lives – this is affecting the region's economies and productivity .
To accelerate the fight against cancer, the Union of International Cancer Control (UICC) and Bayer brought together relevant stakeholders (policy-makers, patients, doctors, medical societies, non-governmental organizations and the healthcare industry) at the World Cancer Congress 2018 to jointly take action in improving cancer care in ASEAN countries. The goal is to facilitate an open dialogue among the relevant stakeholders and jointly work towards the establishment of a future care framework which will drive improvement of cancer care and access to innovative oncology medicines in ASEAN, with the ultimate goal of enhancing outcomes for patients and society.
Recognizing the value of innovative medicines in cancer care
Although more people are diagnosed with cancer, the good news is innovative cancer medicines along with better care, are helping cancer patients to live longer and with a better quality of life. Over the past few decades, death rates of many cancers have lowered – from a death sentence, to chronic condition, or even cured.
- In the 1970s, fewer than half of the people with cancer survived 5 years. Today, 2 out of 3 people diagnosed with can¬cer survive at least 5 years .
- New therapies have contributed to significant declines in cancer death rates around the world since its peak in 1991. Approximately 73 percent of survival gains in cancer are attributable to new medicines ,
- In the United States, for example, treatment advances in cancer saved 23 million years of life, and added US$1.9 trillion to society based on improved productivity, extended life expectancy, and other factors between 1988 and 20004. By 2026, it was estimated there will be more than 20 million survivors in the US, a significant increase from more than 15.5 million in the 20164, .
Better treatment and improved survival mean people are able to return to their usual daily routines, resume work, and play an active role in society and the economy. Based on a review of existing literatures in the UK, more than 75% of cancer patients are able to return to work following a cancer diagnosis. Some studies in Europe and Japan have also suggested a figure of 80% or higher in certain cancer types due to innovative therapies , , .
Incremental advances in cancer treatment offer hope to patients
Cancer treatment has evolved from pain palliation to chronic management, with targeted therapies which halt/slow down disease progression, minimize complica¬tions, improve quality of life, prevent hospitalizations and surgeries, reduce side effects, and even curative options, in best cases. New, innovative cancer treatment offers hope to patients who have limited or no other options. Incremental advances in cancer treatment make a huge difference to patients who do not respond to currently available treatments. Adding multiple lines of treatment in cancer can help patients extend their lives and improve the quality of their lives.
Unmet needs in access and cancer care in ASEAN
Given the significant benefits, it is vital that patients in need have access to new, innovative cancer medicines. Cancer policies and awareness in the ASEAN nations differ country-to-country due to the unique local healthcare systems. In particular, there is little uniformity when it comes to frameworks for access to innovative cancer medicines, leading to delays and access disparities for patients across ASEAN countries. There are also gaps in knowledge and awareness of cancer among the general public, lack of alignment in care priorities and delivery infrastructure, as well as a lack of early diagnosis and in enhancing treatment outcomes.
In some countries, there are still room for improvement in reimbursement frameworks and decision processes, to support the effective use of medicines among clinically-eligible patients, ultimately avoiding treatment delays and substantial loss of life years.
Furthermore, there are disparities in health plans that do not – or only partially – cover the provision of cancer drugs, while some price control mechanisms and policies can also result in restricted patient access. Consequently, some patients find themselves having to pay for all expenses out-of-pocket, despite the majority not having sufficient funds to cover their treatment.
These unmet needs can be further discussed in the context of liver cancer, a common cancer across different ASEAN countries. Here's an overview of the situation in Malaysia, Thailand and Vietnam.
Malaysia
Cancer persists as one of the five main causes of national mortality over the past 20 years, and the number of cases has since escalated. In 2015, cancer contributed to 13.6% of all deaths in Ministry of Health hospitals compared to 8.9% in 1996. In Malaysia, there is good access to traditional cancer treatments such as surgery and chemotherapy. However, for patients who do not respond to these treatments, the access to cutting-edge, innovative cancer medicines including targeted therapy, precision therapy and other new treatment paradigms is limited, placing cost burden on patients and their families.
Liver cancer is the sixth most common cancer in Malaysia . The annual mortality rate for liver cancer per 100,000 people was 6.1% in the year 2013, an increase of 42.8% since 1990 . This is due in part to a lack of understanding of the disease. Hepatitis B virus (HBV) remains the leading cause of HCC in Malaysia. However, Hepatitis C virus (HCV) infections are increasingly playing a role in the growth of the disease and are expected to continue to rise in the coming years.
Even though treatment options are available in the earlier stages of HCC, the survival rate is generally very poor as the majority of patients present at a very advanced stage. For these patients, the therapies needed are not available in the official list of reimbursed medicines, resulting in patients having to obtain the medication via a different process which is slow and leads to treatment delays. This unfortunately means that for many, their cancer advances too far to be treated.
Thailand
According to the World Health Organization (WHO), the cancer mortality rate in Thailand in 2012 was 127.8 per 100,000 for men and 82.6 per 100,000 for women - the fifth highest in the Southeast Asian region. Approximately 60% of the cancer burden in Thailand is due to five types of cancers, liver cancer being one of them . Half of Thai patients affected by HCC also have a chronic HBV infection, and cirrhosis is widespread as a common underlying disease. Unfortunately, patients often present in the advanced stages of HCC and thus have mostly poor treatment outcomes .
Notably, Thailand has been successful in implementing a Universal Health Coverage (UHC) system. Since 2002, 98% of the Thai population is covered by national health insurance subsidized by the government , and the country has seen significant improvements in healthcare outcomes for patients. However, cancer patients still have limited access to innovative cancer therapies, as the majority of treatments subsidized are traditional treatments such as surgery or chemotherapy. Only a small number of Thai patients are eligible for the reimbursement of innovative medicines that can benefit them to enhance treatment outcomes with lower side effects than the traditional regimens.
Vietnam
Non communicable diseases (NCDs) represented 72% of total mortality in Vietnam in 2010, with 29% of this due to cancer . Vietnam has implemented initiatives to help tackle the growing cancer incidences, addressing problems such as a lack of early screening and putting an emphasis on public knowledge of the disease .
Liver cancer is the leading cancer in term incidence and mortality in Vietnam . In 2012, the WHO estimated that Vietnam was one of the countries with the highest mortality rates from liver cancer, which is mostly attributed to the sheer number of people infected with hepatitis B virus (HBV) and hepatitis C virus (HCV) . Though the capacity for cancer diagnosis and treatment has been strengthened significantly in Vietnam, treatment efficacy still needs greater support in terms of guaranteeing access to medicine and advanced treatment techniques.
Advocating for better access and cancer care in ASEAN
It is vital that new, innovative cancer drugs reach patients in ASEAN countries who are in need without undue delay. With the incidences of cancer predicted to continue increasing, and to improve the current standard of care, ASEAN countries would need to evaluate and prioritize the removal of access delays and barriers to innovative cancer therapies for patients. Particularly for HCC, there should be at least one first-line innovative treatment for liver cancer accessible for clinically-eligible HCC patients. This, in tandem with measures such as improving cancer awareness, prevention and early diagnosis, will effectively relieve the cancer burden in ASEAN, ultimately benefitting patients and society.
Stronger collaboration among stakeholders
Public and private healthcare sectors, along with non-governmental organizations must collaborate more strongly to combat access barriers to innovative cancer medicines in ASEAN. Many people in ASEAN are without adequate access to cancer care. The challenges faced by countries over access to medicines are multi-faceted and require contributions from all stakeholders. There is a clear need for governments to extend financial protection through social health insurance and publicly-supported cancer care to relieve patients from cost burden of cancer treatments. Patient-assistance programs (PAP) supported by companies together with partners from local healthcare systems and NGOs will also help to close such healthcare gaps.
In Malaysia, for example, Bayer launched BayPAP, a PAP which provides medication assistance to liver cancer patients suitable for treatment with sorafenib in 2009. A second PAP was launched in 2014 to assist patients with colorectal and gastrointestinal stromal tumour cancers who are treated with regorafenib. In 2018, Bayer together with the healthcare services provider, Zuellig Pharma enhanced the PAP with the BayPAP Web App, to gives patients easy access to a one-stop web-based medication assistance resource which significantly reduces the lead time for the redemption of free medication from a few weeks to just 3 days. The app also provides doctor with easier access to their patients' healthcare review and follow-ups which ultimately help facilitate better treatment outcomes. BayPAP has successfully benefitted over 300 patients to date.
In Vietnam, Bayer sponsored a PAP managed by the Bright Future Fund (BFF), a member of UICC, to provide Vietnamese patients suffering from HCC or advanced renal cell carcinoma (RCC) with better access to sorafenib. Approved by Vietnam Ministry of Health, the PAP was launched in 2016, and it has since provided partial funding to patients who are diagnosed with HCC or RCC, and are prescribed with the targeted oral cancer drug. Within its first year of implementation, the PAP supported 852 HCC patients and 52 RCC patients across 19 hospitals and medical centers.
Cancer is an incredibly complex set of diseases with more than 200 different types, and a most formidable foe: it can use the human body to resist treatment, and continues to be a leading cause of death worldwide. Ongoing innovation and clinical development are critical to continue to extend and improve the lives of those impacted by cancer. A pro-inno¬vation environment for the industry to continue the development of innovative medicines is good for patients and society and helps put healthcare systems on a more sustainable path.
The "Taking Action Together: Improving Care for Cancer Patients in ASEAN countries" session at the WCC facilitated an exchange among relevant stakeholders (policy-makers, patients, doctors, medical societies, and the healthcare industry) on ways to improve access to innovative medicines in ASEAN countries and aimed to drive stronger partnership amongst stakeholders towards the enhancement of treatment outcomes and access to innovative oncology medicines in ASEAN, ultimately benefitting patients and society.