Action on European Cancer Care Disparities 'Essential'

Liam Davenport

October 10, 2016

COPENHAGEN — Ambitious targets to disseminate best practice and improve access to care, alongside measurable parameters to determine progress, are essential if the substantial disparities in cancer outcomes between different regions and countries in Europe are to be closed up, conclude leading experts.

In a special session here at the European Society for Medical Oncology (ESMO) Congress 2016, a panel of leading oncologists and patient advocates held a debate with an audience of representatives of organizations from across the world to find solutions to the problem of cancer outcome disparities.

Although it was underlined that disparities in European cancer incidence and mortality are the result of a series of differences across the spectrum of cancer care and management, measures can be taken to help reduce the gaps between countries and save hundreds of thousands of lives.

Session co-chair, Ian Banks, MD, president of the European Men's Health Forum, Brussels, Belgium, and visiting professor in men's health, University of Ulster, United Kingdom, told Medscape Medical News that this requires translating European-level recommendations down to the local level.

He said, "You can have overarching guidelines and so on, but you invariably have to modify them for a local environment in which you are working. A good example would be trying to compare the delivery of services in the UK, for example, with Turkey. They are completely different systems, so therefore the guidelines would not fit everything."

He pointed out, however, that "there are certain overarching issues that are common to all people in all parts of the world, let alone just in Europe, and those are the areas that are particularly of concern because that's where the disparities really are bad."

In an interview, Dr Banks said that, in a lot of cases, improving standards across Europe and eliminating disparities in cancer care are not just a case of having access to the latest and most expensive treatments.

He said that one element that has been missed, including by the European Cancer Concord in its recent publication, is primary care, "and yet that is a very cost-effective side of medicine."

He added: "An awful lot of the treatment and management can take place in the community, and we know that patients like that and we know that especially if it means that they can go back to work. That is particularly important in Europe."

 
Not everything is about money. Some of it is about the mindset and how we actually use the existing services. Dr Ian Banks
 

"Not everything is about money. Some of it is about the mindset and how we actually use the existing services," he said.

Survival Differences Across Europe

Ana-Maria Forsea, MD, PhD, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania, opened the session by setting out what is known so far about cancer disparities in Europe.

She noted that although the average fatality rate for cancer across Europe of 0.47 is high, there are major differences in the incidence and mortality of all cancers across the continent and that a North–South, West–East gradient is seen in all statistics.

Survival differences are also seen across cancers, with, in some cases, the difference between the best-faring country and the worst-faring country in terms of survival almost 50%. This relevance of this was underlined by a recent analysis of World Health Organization data, reported on by Medscape Medical News, which showed that cancer is now responsible for more deaths than cardiovascular disease in 12 European countries.

Dr Forsea explained that cancer outcome disparities result from "a huge mountain of outcomes that are visible," including incidence, mortality, survival, and overall burden. "However, beneath these visible differences in outcomes are disparities across the whole spectrum of cancer care," she added.

This includes disparities in prevention and screening, diagnosis, and the availability of drugs and treatments and of multidisciplinary care, alongside disparities in survivorship care and cancer registration and reporting. These are underpinned by disparities in healthcare resources and management.

Huge Disparities in Cancer Drug Availability

Taking, for example, the availability of drugs, there are huge disparities in the access to innovative drugs. As reported by Medscape Medical News, a survey of 30 European countries presented at ESMO 2016 showed that more than 5000 patients across Europe do not have access to the latest drugs for metastatic melanoma, including agents targeting BRAF mutations and novel immunotherapeutics, and that there is a huge disparity between Western and Eastern Europe.

However, there are also large disparities in access to what are termed "essential" anticancer drugs, with a recent survey revealing stark differences across Europe in the availability and out-of-pocket costs of anticancer drugs for the treatment of common cancers, such as lung cancer, colorectal cancer, and metastatic breast cancer.

These issues are driven by large differences in average annual net earnings across Europe and are reflected in differences in total health expenditure per capita, which is correlated to the cancer incidence/mortality ratio.

Dr Forsea said that although the availability of resources is one of the most important drivers of differences in cancer survival between countries, it does not explain the whole picture because governance and access to care also play a huge part.

She noted that many recently published recommendations, guidelines, and policy papers set out best practice and good-quality care at the European level. However, "their implementation is the business of each member state," she pointed out, which "relies on self-reporting."

Dr Forsea concluded that action on the implementation of guidelines requires the measurement of progress via measurable parameters, which will, in turn, allow the objective assessment. This, she said, can be achieved only with long-term planning and investment and the right tools.

What Can Be Done?

For the second presentation, Peter Selby, MD, professor of cancer medicine at the University of Leeds, United Kingdom, and president of the Association of Cancer Physicians and the European Cancer Concord, set out what can be done to tackle cancer care disparities.

He discussed the European Bill of Cancer Patients' Rights, which was developed by a coalition of patient advocacy organizations and healthcare professionals to address the inequalities facing patients with cancer in Europe.

Dr Selby went on to say that lifting country-specific cancer survival for each country to the European average or the top quartile would result in 50,000 to 100,000 lives being saved every year and, crucially, that the knowledge to improve outcomes already exists.

It has already been established that best practice in cancer care consists of, for example, prevention, screening, prompt diagnosis, and prompt access to care, which in particular includes patient-centered, specialized, and integrated multidisciplinary care.

However, he said, "Clearly we are not achieving best practice compared with where we are now. Otherwise we would not have the disparities that have been described."

Dr Selby went on to discuss the goals that have been proposed by the European Cancer Concord to tackle the problem. These include 70% long-term survival for patients with cancer by 2035, known as the 70:35 vision.

Another is to focus on two major mechanisms of delivery: sharing of best practice and an emphasis on research and innovation, including in the way care is delivered. A European center should also be established to help achieve those goals.

He explained that for a country to achieve a 40% overall survival rate at 10 years, basic diagnostic and treatment systems must be established. Adopting known best practice for diagnosis and treatment lifts that survival rate to 50%, while the development of new knowledge generated through ongoing research that is rapidly translated into clinical practice takes 10-year survival to 70%.

"Currently, the best long-term survival figures in Europe are in the high 50%," he noted.

With mortality, quality of life, and patient experience all vital aspects of cancer care, Dr Selby underlined that cooperation and a strong common purpose between all stakeholders in cancer care are essential if the disparities are to be tackled.

He concluded that "a commitment is needed to create and sustain a core professional capacity to support this work."

Discussion

The presenters were subsequently joined onstage by session co-chair Francesco De Lorenzo, MD, from the European Cancer Patient Coalition, Brussels, Belgium, and Alexandru Eniu, MD, PhD, from Cancer Institute "Ion Chiricuta" in Cluj-Napoca, Romania, and chair of the ESMO Global Policy Committee.

The discussion was thrown open to the floor, and Mark Lawler, MD, from the European Cancer Concord and Queen's University Belfast, United Kingdom, wrote down all the suggestions that emerged from the debate between the panel and the audience, gathering them into themes to form the basis of a report of recommendations for tackling cancer disparities.

The hour-long debate, which took in contributors from across Europe, as well as Australia, Canada, and Brazil, generated 29 topics, which included the challenge of implementing at the local level, that there should be a focus on surgery and radiotherapy and not just cancer drugs, the development of stratified recommendations that will allow low-resource countries to achieve acceptable standards in cancer care, involving the private as well as public sector, and identifying what works best in different types of scenarios and ensuring that this information is shared.

No funding was reported. The participants disclosed no relevant financial relationships.

2016 European Society for Medical Oncology (ESMO) Congress. "Cancer Inequalities: Bring Me Solutions Not Just the Problems!" Presented October 8, 2015.

Follow Medscape Oncology on Twitter: @MedscapeOnc

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