Economics of Cancer & the Cancer Drugs Fund

Question 1

Why are the economics of cancer important?

Answer 1

• Cost; US Cancer Costs in total for 2010 were $124.57 billion, projected to rise to $157.77 by 2020
  > Total sales of the top 20 cancer ‘brands’ in the seven major markets of the US was $37.2 billion in 2011

Question 2

What cancers are in ‘The Big 4’?

Answer 2

• Breast
• Colorectal
• Lung
• Prostate

Question 3

What is the oncology market ‘fragmenting’ after such success, in turn marking it harder for drugs to reach blockbuster status?

Answer 3

• Developers starting to focus more on niche subsets of patients w/specific genetic mutations; targeted therapies
  »> E.g. 3rd-line HER2 breast cancer treatments

Question 4

What was the NHS cancer drugs spend like in 2014-15? How much of this was attributed to hospitals?

Answer 4

• 15.5 billion GBP (10% of budget)

- Hospital use accounted for 42.9% of total cost

Question 5

Why is a biological that is coming off-patent regarded as a biosimilar than a generic, and what is the difference?

Answer 5

• Often large molecule drugs; v. difficult to replicate for other companies/reach same efficacy profile if replicated
• Thus become “bio-similar’; same company still makes the drug that had it under patent, but it is made availible for a cheaper (20% cut in price)

Question 6

How is Tamoxifen an example of an ideal patent-to-generic anti-cancer drug?

Answer 6

• In 2001 (under patent), global sales of TAM totalled $1 billion
• They cost around 1 GBP per tablet in 2001 (Nalvodex)
  »> Today, the NHS pays 8p per tablet (generic)
  > For 500,000 daily doses, the cost to the NHS for TAM annually is 15 million GBP
  > Rare for efficacious AND low cost (v. effective in prophylactic measure in heredity-risk breast cancer)

Question 7

In the BNF, what is the Public List Price, and does the NHS/Trusts pay it?

Answer 7

• Price given by manufacturer

- But NHS/Trusts often negotiate a lower price; will not pay public list price

Question 8

What is the pharmacist’s role in choosing and recommending anti-cancer medicines, fiscally?

Answer 8

• To consider cost/profit considerations

- Look at BNF Drug Entry’s bottom line; gives Public List Price

Question 9

What do NICE Technology Appraisals entail?

Answer 9

• Review of the availible evidence for clinical and cost effectiveness
• Covering medicines a treatments such as:
  > Medicines
  > Medical devices
  > Diagnostic techniques
  > Surgical procedures
  > Health promotion activities

Question 10

What is the acceptable ICER (Incremental cost-effectiveness ratio) for NHS-approval?

Answer 10

• < 20,000 GBP per QALY gained

- Cost utility analysis/health technology assessment/cost effectiveness analysis

Question 11

What does the Markov cost effectiveness model entail?

Answer 11

• Designed to represent disease progression of a cohort of patients with a particular cancer, the clinical pathway and clinical decision-making consistent with UK practice
  > Pre-progression (aim)
  > Post-progression (drug wants to reduce probability of advancing to Post-progression)
  > Death ‘absorbing state’; possibility from both trees

Question 12

What are the conditions for ‘End of Life (EoL)’ approved drugs?

Answer 12

• Politically driven (not economically)
• Treatment indicated for patients w/a short life expectancy; < 24 months
• Sufficient evidence to indicate treatment offers extension to life; normally at least 3 months compared w/NHS treatment
• Treatment is licensed or otherwise indicated for small patient populations (< 7000)
• If EoL approved; goal posts for QALYs moved and ‘reweighted’ - threshold increased to 50,000 GBP pre QALY gained (drug doesn’t have to be as cost effective)

Question 13

How does vial-sharing reduce cost?

Answer 13

• Doesn’t waste excess drug where the complete vial’s contents are not required to adequately dose the patient

Question 14

What is the Cancer Drugs Fund?

Answer 14

• CDF enables patients access the cancer drugs doctors think will help them
• CDF will access funds in excess of 1.1 billion GBP from 2010-16
• Health authorities could offer drugs otherwise not availible on the NHS
• Access

Question 15

What reasons are drugs not normally accessible on the NHS (but otherwise possible from the CDF)?

Answer 15

• Drugs appraised by NICE and not recommended on the basis of cost effectiveness
• Drugs recommended for restricted access
• Drugs not, or not yet, appraised by NICE

Question 16

What are the two mechanisms for clinicians and patients to access drug treatments via the CDF?

Answer 16

• National CDF Cohort Priority List

- Individual CDF Requests (ICDFRs; most this way e.g. Blueteq; online request system for CDF by physicians/pharmas)

Question 17

What are some examples for the requirements of a request to the CDF Cohort Priority List?

Answer 17

• Application to be made by and to be prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer therapy
• Indication of cancer (e.g. NSSLC)
• Conditions for treatment e.g. maintenance after 1st line chemotherapy
• Performance Status 0 or 1 at time to commence maintenance w/CDF drug

Question 18

What are the cons of the CDF?

Answer 18

• For every QALY gained by the CDF, 5 QALYs are lost across the NHS
  »> Decision not made on benefit

Question 19

What does the joint NICE and NHS England public consultation on proposals for the use of CDF aim to achieve?

Answer 19

• From April 2016
• To provide the means for selected cancer drugs w/uncertain value to move into and out of the CDF; becoming a transitional fund to facilitate patient access w/tightly focussed research, aimed at securing the best outcomes for patients.