CancerPartnersUK

The NHS and cancer care

Karol Sikora, Medical DirectorProfessor of Cancer MedicineImperial College, LondonMarch 2009

What people living with cancer want

the best chance of cure with good quality of lifehonest, clear information on available optionsto have the diagnostics fast-tracked to 3 daysto see the same specialist at every visitto access the latest scientific developments convenient, streamlined, focused services as

close to home as possible with dedicated car parking

to be treated in a decent environment with dignity

to get the best care without worrying about its cost

The National Cancer Plan – 9 years on

Up to £0.5bn added per year to NHS cancer care for last 5 years – but this now stops

NHS budget tripled to £102bnTarget metrics in place but still running with

huge under capacity in diagnostics and RTStaffing problems in RT leading to delays,

rationing and lack of innovationFinancial meltdown imminent - high cost drugs,

IMRT and lack of ambulatory care facilitiesContinual evolution of stakeholders - PCTs,

SHAs, Cancer Networks and NHS Trusts Increased patient empowerment and demandSurvival data still poorest amongst EU13

Eurocare 4 - four commonest cancers

0

10

20

30

40

50

60

70

80

90

ENG FRA GER SWI POL

colon

lung

breast

prostate

all

5

NHS

CORE SERVICES

Novel drugsNovel devicesAdditional therapiesComplementary medicine

DEMAND LED SERVICESTIME

The cancer demand pyramid

NHSInsurersRegulatorsNICE Politicians

PharmaProvidersPatientsAdvocacyPoliticiansSocietyLegal

Breast

Lung

Colorectal

Prostate

20102000 2005

2010 20152000 2005

2010 20152000 2005

20102015 20202000 2005

KeyMAbs

Vaccines

Anti-Angiogenesis

Kinase Inhibitors

Apoptosis Inducers

Anti-Sense

Gene Therapy

2015 2020

2020

base case launch years in the US

Predicted NDA dates for molecular therapiesPredicted NDA dates for molecular therapies

7

Targeted therapies could lead to financial meltdown

drug generic manufacturer

yearly cost

Herceptin traztuzumab Roche £60K

Mabthera rituximab Roche £50K

Nexavar sorafenib Bayer £30K

Glivec imatinib Novartis £60K

Erbitux cetuximab BMS £50K

Avastin bevacizumab Genentech £60K

Tarceva erlotinib Roche £40K

Sutent sunitinib Pfizer £40K

Tykerb lapatinib GSK £30K

Iressa gefitinib AZ £40K

NICE - Trastuzumab (Herceptin) early breast cancer

Jun 05 ASCO data presentedAug 05 DH referred to NICEOct 05 Health Minister announces

availabilityNov 06 Debated in ParliamentDec 05 Patient goes to High CourtApr 06 Patient wins in CourtMay 06 EMEA approvalJun 06 NICE publishes positive draft

guidanceAug 06 Fast-track guidance published by

NICE

8

NICE - Sunitinib (Sutent) renal cell cancer

Jan 06 FDA accelerated approvalJul 06 EMEA Market authorisationJun 08 Health Minister says top-ups not

allowedAug 08 NICE negative final guidanceAug 08 protest from 26 academic oncologistsDec 08 DH review backs top-up paymentsFeb 09 NICE draft guidance approves 1st line

onlyFeb 09 newspaper protest at unfairnessFeb 09 NICE permits 2nd line use after IFNMar 09 final guidance due

9

10

11

12

Bevacizumab (Avastin) - colon cancer

NICE - Lapatinib (Tyverb) breast cancer

Feb 07 final scoping studyMar 07 FDA NDA passedApr 07 closing date for evidenceJan 08 1st appraisal meetingJun 08 EMEA market authorisationSep 08 2nd appraisal meetingNov 08 3rd appraisal meetingJan 09 4th appraisal meetingMay 10 expected guidance

13

14

Ratio of E13: UK and TOP COUNTRY: UKDRUG GENERIC UK E13 TOP COUNTRY CANCER

ERBITUX cetuximab 1 10 22.5 FR colon

SUTENT sunitinib 1 3.1 4.8 AS renal

VELCADE bortezomib 1 2.7 5.3 FR myeloma

NEXAVAR sorafenib 1 6.7 13.5 FR renal, liver

AVASTIN bevacizumab

1 7.6 18.0 FR Colon, breast

TARCEVA erlotinib 1 5.3 11.7 FR Lung, pancreas

HERCEPTIN traztuzumab

1 1.2 1.7 SW breast

15

Cost per QALY inflation

Cancer funding UK per PCT

Centre for Health Economics, York, 2007

M&C Cancer Network: PCT spending on cancer

Spend on Cancer by PCT 2004-5

-

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

Bebington &West Wirral

EllesmerePort AndNeston

SouthSefton

Know sley St Helens NorthLiverpool

Birkenhead& Wallasey

CheshireWest

Southportand Formby

SouthLiverpool

CentralLiverpool

Warrington WestLancashire

Sp

end

(£

Mill

ion

s) p

er 1

00,0

00 U

nif

ied

Wei

gh

ted

Po

pn

England Average

18

Are you ill?

No

Yes

Have you got cancer?

No

YesNo

Yes

Have you got medical insurance?

Check the cover. Some insurers are beginning to limit benefits

Remain an NHS patient

NHS oncologist is willing and able to prescribe the most effective drugs? No

Yes

Prepared to self fund?

Legal challenge – There is no legal reason as to why patients cannot top up their NHS care

Survive on NHS

Win

Purchase drugs for oncologist to administer on NHS

No

Yes

No Yes

Will the oncologist let you top up your cancer care while remaining an NHS patient?Some oncologists will let you purchase cancer drugs that can be administered as an outpatient and remain an NHS patient. It gets more complicated, if the drug needs to be administered in hospital.

Intimate wish to take up residency and drug will be prescribed Is the drug available

in England, Scotland, Wales or Northern Ireland Yes No take up residence?

Purchase a second opinion until Yes

Complain to the Chief Executive of Hospital (copying the Healthcare Commission)

Complain to local PCTIt is generally accepted that the majority of cancer sufferers who challenge their PCT win

No

No

Yes

No

Yes

Yes

Survive on NHS

Make cancer charities aware of your challenge – they can be a mind of information

If your case goes to the PCT Exception Committee and it is declined – challenge the decision and the authority of its members

Write to your local MP

Get in touch with Doctors for Reform, Halliwells Solicitors, Pamela Northcott Fund

Get as much publicity as possible and do not accept what you are given Get in touch with the drug manufacturer

Win

Survive on NHS

Fail

No

Yes Win

Survive on NHS

Fail

19

Providing cancer care in 2029 Cancer as a chronic, controllable illness

Governments as regulators and insurers – not providers

Healthcare, insurance, pharmaceutical, academic partnerships create novel global provider vehicles

Personalised medicine, NPT black box systems, implanted chip monitors, molecular diagnostics

Cancer ‘hotels’ in most towns New roles for cancer professionals Empowered informed consumers not patients –

option appraisal Co-payment – biomarkers to reduce costs Total care and compressed morbidity