The rise of chronic disease in BRIC markets

The epidemiological profiles of the growth nations are evolving. The benefits of increased economic prosperity and the incremental impact of healthcare reforms have led to a shift in disease patterns – slowly inching away from communicable diseases and those associated with poor nutrition, towards 'lifestyle' diseases that are more common in Western markets.

The World Health Organization (WHO) projects that by the end of the decade, the largest increase in deaths from noncommunicable diseases (NCDs) like cancer, cardiovascular and respiratory disease, and diabetes will occur in countries with developing or transitional economies. In response to the escalating economic and individual costs, the WHO wants greater action to tackle NCDs. This presents opportunities for pharma to develop new markets for existing chronic disease treatments.

In addition to changes in population demographics, including increased urbanisation, smoking, obesity and pollution are the factors most likely to drive morbidity trends in Brazil, Russia, India and China (BRIC). In particular, diabetes and cancer pose two of the greatest threats. Pharma executive respondents to the Booz study of emerging markets believe these two diseases will experience the highest growth rates over the next five years.

Lifestyle diversity
The need for pharma to tailor localised approaches to the BRIC nations is further illustrated by analysis of population lifestyles in individual countries. Data from Kantar Health's 2012 National Health and Wellness Survey (NHWS) highlights the diversity of attitudes and behaviours across these key growth markets.

For example, although fewer patients in urban China (24 per cent) are classed as obese or overweight than in Brazil (49 per cent) or Russia (51 per cent), the increasing westernization of lifestyle habits and diets in China means that its rate of diabetes diagnosis is outstripping every country in the world. Conversely, smoking remains a major challenge in Russia, where 33 per cent of the population currently smoke, compared to 21 per cent in urban China and 20 per cent in Brazil. Similarly, alcohol consumption in Russia (76 per cent) outranks China (60 per cent) and Brazil (53 per cent) – and is a leading cause of adult mortality, especially among men. Almost 50 per cent of the Russian population are overweight.

Russia
NHWS data shows that circulatory diseases are the main cause of death in Russia, followed by cancer, which accounts for approximately 15 per cent of mortality. Russia's adult population totals 85.7 million people, around 2 per cent of which have been diagnosed with some form of cancer. This rises to 3 per cent when including self-reported cancer sufferers that prefer to treat themselves. A massive 44 per cent of adults report metabolic diseases – including diabetes, hypertension and obesity – with 32 per cent officially diagnosed.

Cardiovascular diseases – such as heart attack, stroke, DVT and atrial fibrillation – also present a major problem in Russia, with 46 per cent of self-reported sufferers (39 per cent being diagnosed).

China
The disease profile of China resembles more developed countries, with 85-90 per cent of deaths due to NCDs and injuries. Around 160 million Chinese – mostly between 18 and 59 – suffer from hypertension, while diabetes prevalence is forecast to double to over 42 million people by 2030. Likewise, with 350 million smokers in China, it is projected that tobacco use will account for one third of all deaths in the country by 2020. Cancer prevalence is currently 1 per cent of the adult urban population (253.2 million), while 25 per cent report metabolic conditions (including diabetes). Thirty seven per cent of cancer patients and 27 per cent of patients with metabolic conditions prefer to treat themselves with an OTC medicine than depend upon a doctor giving them a prescription medication.

Brazil
Cardiovascular disease and cancer are the leading causes of death and disability in Brazil. Analysts predict that ischaemic heart disease and stroke mortality will almost triple in the next 20 years. By 2020 more than 30 million people will be over the age of 60.

The adult population in Brazil totals more than 137 million, 37 per cent of which report a metabolic condition (such as diabetes or hypertension) – with 27 per cent officially diagnosed. Around 5.4 million adults are diagnosed with diabetes, 87 per cent of which have type 2.

Thirty per cent of the adult population have been diagnosed with a cardiovascular condition, though 13 per cent of sufferers prefer to treat themselves with an OTC medication. 29 per cent report gastrointestinal conditions such as gastroesophageal reflux disease (GERD), IBS and diverticulitis. Cancer prevalence is between 1-2 per cent.

India
Over the next decade, with India's population forecast to grow by 1.3 per cent, the prevalence of diseases such as cancer and diabetes is likely to increase by between 25-40 per cent. The country is already experiencing a shift in disease profile, with a major growth in chronic diseases. In 2010, India boasted the largest number of diabetic patients in the world, with more than 41 million sufferers. According to a 2007 report from PwC, this is projected to reach 73.5 million by 2025.

Likewise, the country's ageing population – where forecasts predict 199 million Indians will be over the age of 60 by 2028 – is already leading to increased demand for medicines to treat CNS and cardiovascular diseases.

Diabetes
The BRIC nations are traditionally characterised by low diagnosis and awareness rates for diabetes, as evidenced by a series of studies by Kantar Health. In Russia, for example, Type 2 diabetes (T2D) is modest, but a lack of epidemiological and health outcome data on the prevalence of those at risk may indicate a large undiagnosed population. A 2012 Kantar study of the diabetes burden in Russia concluded that the non-T2D population presented a significant enough number of risk factors to suggest that T2D prevalence could be much higher.

Likewise, a Kantar study in India showed that education around T2D is poor – with a third of patients unaware of the type of diabetes from which they suffered, and almost 60 per cent believing the disease was caused by stress. In Brazil, a similar Kantar study revealed that 72 per cent of T2D patients are unaware of their HbA1c and FPG levels, while of those that are aware almost a fifth (18.3 per cent) report uncontrolled levels. These trends indicate an increased need for education around disease management and, perhaps, access to more effective treatments. In Brazil, 93 per cent of those diagnosed T2D use prescription medications; 79 per cent use biguanides, with metformin and Gilfage the leading brands, while 26 per cent use sulphonylureas – most commonly Daonil. Insulin plays an important secondary role and is used by 28 per cent of patients. The majority of Indian patients continue to use allopathic oral medicines, with very few shifted to insulin.

In China, where 3.6 per cent (17.8 million) of the adult urban population have diabetes – 89 per cent of which have T2D – understanding of the condition appears to be greater. Sixty four per cent of patients are aware of their HbA1c levels, though only one in five report blood sugars that are controlled. Almost two thirds of patients use at least one prescription medication. The most commonly used oral/ non-insulin injectables are Metformin (37 per cent), Glucobay (21 per cent), Glipizide (15 per cent) and Tangshiping (11 per cent). The most commonly used insulin is Novolin 30R (21 per cent).

Pharma diabetes initiatives
The burden of diabetes in BRIC nations is huge. In 2012, WHO predicted net losses in national income from diabetes and cardiovascular disease of $557.7bn in China and $336.6bn in India, between 2005 and 2015. In response, pharma has introduced a number of initiatives to help tackle diabetes, particularly in China. In March 2013, Merck Serono and Bristol-Myers Squibb struck a deal to co-promote a variety of formulations of Glucophage (metformin) in China. Prior to that in September 2012, Novo Nordisk invested $100m in expanding its diabetes research facilities in Beijing. In July 2012, Eli Lilly opened a diabetes research centre in Shanghai.

Cancer
Cancer is well established as one of the leading causes of death in the BRIC countries. So how is the industry approaching the disease in the growth nations? Analysis of the uptake of high-cost oncology products in two key cancer markets indicates that not only is progress being made, but opportunities for future growth are significant.

Breast cancer, one of the most common cancers worldwide and the most frequent amongst women, ranks as the most prevalent cancer in Brazil and is also very prominent in China. Kantar Health data shows that in Brazil, almost half of stage I and II patients (48.5 per cent) undergo breast conserving surgery (BCS) and radiotherapy (RT) in combination with chemotherapy. First-line treatment in China combines surgery and chemotherapy for 24.5 per cent of patients. At stage III, both China (34.9 per cent) and Brazil (45.5 per cent) combine BCS, RT and chemotherapy. For late-stage patients, Brazil physicians are more likely to use an anthracycline-based regimen without a taxane in the first line, gemcitabine, paclitaxel or a combination of both in the second-line and other chemotherapeutics, such as vinorelbine for the third-line setting. Only a small group of patients (5 per cent) will receive Xeloda. In China there has been a rise in the use of Xeloda in combination with docetaxel as a second and third-line treatment.

Prostate cancer is the world's second most common cancer in men – but is only the tenth most common cancer in developing nations. In BRIC countries, it accounts for 12 per cent of the total incidence and 19 per cent of total deaths each year. More than 77 per cent of new prostate cancer drugs, which generally affects man over 65, were available in BRIC countries for this age group in 2010. Despite this, BRIC incidence is expected to increase by a CAGR of 3 per cent by 2020, a slightly higher rate than the rest of the world. The market for hormone and hormone-refractory prostate cancer (HRPC) therapies in BRIC countries is forecast to grow from an estimated $125m (2009) to $493m in 2020.

Pharma oncology initiatives
The pharmaceutical industry's localisation strategies have led to a number of partnerships to support the treatment of cancer in the BRIC nations. These include GSK's alliance with Binnopharm in Russia, Roche's partnership with Encure Pharmaceuticals to develop affordable versions of Herceptin and MabThera in India, and Eli Lily's 2012 collaboration with Strides Arcolab to jointly manufacture and distribute generic cancer drugs in developing markets.
In February 2013, AstraZeneca (AZ) announced a collaboration with one of Russia's leading cancer research institutions, the Petrov Institute – this follows the 2007 opening of the AZ Innovation Centre, China, a translational science centre specialising in cancer research.

The changing demographics of the developing nations is certainly leading to an increase in the incidence of cancer and diabetes, as well as cardiovascular diseases. At present, pharma is steadily putting the building bricks in place, but as the BRIC economies mature and local healthcare systems become embedded, the growth opportunities in these key disease areas will be significant.

This article was originally published in the PME supplement Pharma and BRIC