COMMENTARY

The Never-Ending Global Struggle With Drug Costs

David J. Kerr, CBE, MD, DSc

Disclosures

November 16, 2021

This transcript has been edited for clarity.

I'm David Kerr, professor of cancer medicine at University of Oxford. I'd like to talk about a paper that's just been published in Lancet Oncology by a distinguished group, many of whom are on the World Health Organization (WHO) panel for developing the essential cancer medicines list.

This group undertook a cross-sectional international survey across 82 different countries, covering the range of high- to middle- to low-income nations. The survey was open to practicing cancer medicine physicians who were routinely prescribing cancer medicines, chemotherapy drugs, targeted agents, and so on. They managed to get responses from about 950 oncologists. I must be honest, I'm not a huge fan of surveys. I think there's a potential for a huge selection bias — how representative they are, what fraction of the total population of oncologists is represented, are they at academic centers, are they working, and so on and so forth.

Nevertheless, this was a noble attempt to get a feel for which of the medicines listed by WHO are used routinely in clinical practice. The oncologists were asked to list their top 10 favorite drugs — a clever approach — and no surprise, the vast majority of these, apart from osimertinib, were on WHO's essential medicines list; that's a good correlation. In 75% of cases, the top 10 drug list overlapped, whether from high- or low-income countries. That's interesting.

The vast majority of drugs were conventionally cytotoxic drugs that were all approved before 2000; old friends, like doxorubicin, 5-fluorouracil, paclitaxel, cisplatin, and so on. The drug class that differentiated high- from low-income countries most clearly, almost in a binary fashion, was access to immunotherapeutic drugs, driven by cost.

Other observations — and again, no surprises — were that the potential for catastrophic additional spending was much more common in low-income countries, in which out-of-pocket expenses could bankrupt families, as simple as that. This caused me to think of a few issues. First, it's interesting how we always focus on drug expenditures. We do this within my own healthcare system, within my own hospital. It's always easy to draw a circle around drug spending, even though, by and large, it only accounts for 10%-15% of the total health budget. It's well circumscribed and therefore there's a strong focus on it. That's one thing.

Second, I'm thinking about the drug chain of access from the pharma company through distributors, through middlemen, through pharmacists, through the various mark-ups, before the drug gets to the clinical front line. This is something that is of real interest. How can we make innovative medicines available to those in low-income countries if we cannot make generic drugs available? This is one of the findings highlighted in this paper.

Finally — and I know I come back to this time after time — if we now have a relatively clear sense of what the 10 most important anticancer drugs are, would it be possible to construct a set of guidelines as to how to best use these? The majority of guidelines that are provided by the professional societies focus on the latest evidence, no matter how expensive the drugs are and no matter how marginally effective. This is what creeps into the guidelines. I would love to see a piece of work in which we just said, these are the top 10 drugs we use, and the best way to use them to treat breast cancer, lung cancer, colorectal cancer, and so on, would be to use these drugs as single agents, or more commonly as combination regimens. That would give some support to our brothers and sisters in low-income countries, who struggle and fight to use even these drugs.

We need to do a wider piece of work. We need to engage further with the global oncology community, to talk about access to cancer medicines. We need to do better.

We need better models of purchasing, where the low-income countries can cooperate together to get better deals from pharma and generic drug manufacturers. We need to improve and simplify the drug supply chain — taking out, as fairly as we can, the middlemen and the potential for markups and so on, and get that sorted out. We need to understand why the price of generic medicines can be so high and financially crippling to many, many families, particularly in a low-income setting.

I think we need to engage the wisdom of the crowd, to do some lateral thinking and go beyond our community of oncologists and healthcare specialists and bring in economists, people who are experts in the supply chain — just a different set of eyes and intellect and vision to look at this problem. Because here we are again, discussing the same thing, running up against the same brick wall. And although we report these findings; although we understand what's going on; and although these findings come, in a way, as no surprise whatsoever, we seem no further forward to finding solutions for them.

One thing I'm going to do is to see if I can find a way of inviting the wisdom of the crowd through a "hackathon." Watch this space, please, because this is something that requires a wider band of thought.

Have a look at the paper. It's beautifully written. It is very interesting despite the weaknesses I mentioned at the beginning. It's a noble attempt to bring insight into what drugs the wider global cancer community uses; what priority is given to these; and how, even so, we often fail to deliver the most common and cheapest of these drugs in low-income settings.

And watch this space for the hackathon. You're all invited. Start thinking now. I welcome any comments, ideas, hypotheses, potential solutions, no matter how wacky the idea may sound.

As always, thanks for listening. Please post comments. Help me, help us, help your brothers and sisters, to see what we can do together to think through what seems to be an eternal problem. For the time being, Medscapers, over and out.

David J. Kerr, CBE, MD, DSc, is a professor of cancer medicine at the University of Oxford. He is recognized internationally for his work in the research and treatment of colorectal cancer and has founded three university spin-out companies: COBRA Therapeutics, Celleron Therapeutics, and Oxford Cancer Biomarkers. In 2002, he was appointed Commander of the British Empire by Queen Elizabeth II.

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