Cancer in all of its multitudinous forms is the second-biggest killer in the European Union, accounting for 30% of deaths in men and 24% in women. But efforts to alleviate such stark statistics are complex and interwoven, with many EU countries finding much to learn from their fellow member states.
Take, for example, Latvia. The Baltic state acknowledges that it needs to improve both its coverage and awareness of cancer screening. At a regional cancer control meeting in Riga last month the Czech Republic, Slovenia and The Netherlands were held up as examples to learn from in areas such as centralised registries, data sources and the organisation of screening programmes for colorectal cancer.
The use and availability of cancer data is one of the issues exercising Josep Figueras, director of the European Observatory on Health Systems and Policies. He notes that currently “cancer registries are of varied quality. Some countries have almost a full population included. Some countries are only samples [and] samples may be biased”.
But, alongside improvements in survival, there have also been improvements in the availability of survival data survival, he notes, pointing to work carried out by the likes of the OECD with its Health at a Glance publications and the European Union-funded European Guide on Quality Improvement in Comprehensive Cancer Control (or CanCon) initiative.
Josep's current roles also include serving as head of the WHO European Centre on Health Policy in Brussels. He juggles that with an academic schedule as a visiting professor at Imperial College London, having previously been the head of the MSc in Health Services Management at the London School of Hygiene & Tropical Medicine.
Given this background, it's perhaps not a surprise that one of his trains of thought about cancer is of a more academic nature. “I don't want to trivialise cancer, [but] from a pure research perspective, looking at performance of health systems, cancer is a very good tracer indicator of how health systems are doing in terms of primary and secondary integration, in terms of primary prevention and secondary prevention, and treatment. It exposes some of the problems of those health systems, that not affect only cancer, but affect other areas of outcomes.”
He adds: “Cancer is an important disease to see [its] impact on the health system.”
Looking to unpick the picture of cancer in Europe, Josep is keen to highlight the impact of social class and co-morbidities on survival. “For instance, depending on your level of deprivation, your attitude towards taking the treatment, towards seeking care will be different.”
This can be seen within the population at large in Central and Eastern Europe, where 65-year-old men who have a low education level live about four years less than the most educated of their fellow citizens. It's a problem that's most acute in the Slovak Republic, Latvia, Hungary, Estonia and the Czech Republic.
I'm a firm believer in faster mechanisms by which you can go from the HTA to the markets
Drilling down to the European picture in cancer, Josep notes that large differences persist when looking at Eastern and Western, Central and Southern Europe, with variation of between 10-15%, particularly in cancers such as breast, prostatic and colon where a number of treatment options exist. Thankfully, as recent data from the OECD showed, the differences between Eastern and Western Europe are narrowing. “[That's] partially because of economic resources, but also because of the adoption of cancer plans and improving the quality and access of coverage.”
Within this picture there's a significant part played by the amount of money that countries invest in tackling cancer, but the relationship between funding and outcomes is not as straight-forward as might be assumed.
“At the end of the day, there is a correlation between the level of expenditure and the survival.” However, it's a nuanced picture. “If you look at the data the correlation is not as clear as you would expect. So, while we need to look at this, the emphasis here is not only more money, but how you put that in the various bottlenecks of the system.” On the point of investment he concludes: “I want to decouple this idea of more resources is the solution. It's much more how you govern and allocate those resources to the right levels of the system.”
From the variation among cancer registries to the recording of how well different treatments work, information is key. Meanwhile, access to diagnostics and treatment is also a factor.
The next five years are expected to see a wave of new oncology medicines that will address significant unmet medical needs, with personalised treatments being potentially transformed by new platforms in areas such as the gene-editing CRISPR technology. That time frame will also see immuno-oncology drugs, both those already making a name for themselves and those still to reach the market, increase their position.
As a recent report on the global medicines outlook through 2021 from the QuintilesIMS Institute noted: 'Payers and providers are developing tools to better assess value and will demand, or create on their own, the evidence to support spending, especially where new treatments would add to already expensive cancer treatment costs.'
Asked how well European health systems are set up to properly assess the value of new cancer treatments, Josep says: “I'm a firm believer in faster mechanisms by which you can go from the HTA to the market [with] faster times to get these things into the market when they work.”
But he adds: “I don't think HTA is the barrier to get innovation in the market. I think it's much more the way the HTA links with the regulators, with the papers, with the payers and all those kinds of issues. So it's much more the way that it links with the governance, with the regulators, with the payers, so that would be the same point.”
He does have a certain amount of sympathy for the pharmaceutical industry, however. “The industry does deserve more certainty [and] I understand as well the challenges, that you develop something and then there is all this varied uncertainty as to whether the payer will take care of this or not. So, the way to go is with some risk-sharing and some risk - trying, as much as is possible, to decrease uncertainty.”
Cancer is an important disease to see [its] impact on the health system
However, he would like to see further changes to the way the pharma industry operates. “The current system by which the industry will lobby desperately for a particular treatment - because, of course, they've done all the investment - regardless of how much value-add it has, is not the way to go.”
In its place he would like to see much more transparency on value and pricing and, where necessary, a focus on risk-sharing. He acknowledges such approaches have been talked about for some time, but maintains they would be “particularly relevant in the area of cancer”.
“Clearly some pharmaceuticals make a huge difference in some cancers, but not in others. We need to thrash out [that] it's not about spending huge amounts of money with the next treatments coming out, but being very rigorous about the quality. Even if the treatment is expensive, it's all about the value and the impact and so on.
“We need to communicate that much better, because we end up seeing systems investing huge amounts of money because of lobbying by the patients themselves or the industry on things that have very marginal benefit, and taking it away from areas of screening or areas of developing better diagnostic facilities or better surgical treatment techniques or better access.
“In some areas, access to a particular medicine makes a huge difference. In some areas it doesn't make any difference.”
It's a debate he thinks should cut both ways. “It could be that a very good pharmaceutical is not adopted in the market because it's not perceived to be cost-effective and make a difference. So I'm not saying it goes always in one direction. In some cases innovation makes a difference. In some cases it doesn't.”
The fight against cancer is often portrayed in combative language, indeed, I spoke with Josep during the War on Cancer conference organised by The Economist. So it seemed appropriate to ask him about the militaristic imagery that often surrounds oncology and whether it's a war that can truly be won.
“The incidence has increased, it has to because we live longer, but the mortality has decreased. We're talking about breast cancer survival at 80% in many countries and similar numbers for prostatic cancer.
“So it's a war that we can really, really win from the preventive, treatment and research sides, and the innovation is amazing. Some of the treatments we have now would be unthinkable, years ago.
“We have had an important impact. We've saved lives. But the potential within the current level of development, the current level of resources, the current level of innovations and treatments is very high.”