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CancerPartnersUK The NHS and cancer care Karol Sikora, Medical Director Professor of Cancer Medicine Imperial College, London March 2009 What people living with cancer want the best chance of cure with good quality of life honest, clear information on available options to have the diagnostics fast-tracked to 3 days to see the same specialist at every visit to 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 £102bn Target metrics in place but still running with huge under capacity in diagnostics and RT Staffing problems in RT leading to delays, rationing and lack of innovation Financial meltdown imminent - high cost drugs, IMRT and lack of ambulatory care facilities Continual evolution of stakeholders - PCTs, SHAs, Cancer Networks and NHS Trusts Increased patient empowerment and demand Survival data still poorest amongst EU13 Eurocare 4 - four commonest cancers 90 80 70 60 colon lung breast prostate all 50 40 30 20 10 0 ENG FRA GER SWI POL The cancer demand pyramid TIME DEMAND LED SERVICES Novel drugs Novel devices Additional therapies Complementary medicine NHS Insurers Regulators NICE Politicians CORE SERVICES NHS Pharma Providers Patients Advocacy Politicians Society Legal 4 Predicted NDA dates for molecular therapies base case launch years in the US Breast 2000 2005 2010 2015 2020 2000 2005 2010 2015 2020 Lung Key MAbs Colorectal 2000 2005 2010 2015 Vaccines Anti-Angiogenesis Kinase Inhibitors Apoptosis Inducers Prostate Anti-Sense 2000 2005 2015 2010 Gene Therapy 2020 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 6 NICE - Trastuzumab (Herceptin) early breast cancer Jun 05 Aug 05 Oct 05 Nov 06 Dec 05 Apr 06 May 06 Jun 06 Aug 06 ASCO data presented DH referred to NICE Health Minister announces availability Debated in Parliament Patient goes to High Court Patient wins in Court EMEA approval NICE publishes positive draft guidance Fast-track guidance published by NICE 7 NICE - Sunitinib (Sutent) renal cell cancer Jan 06 Jul 06 Jun 08 Aug 08 Aug 08 Dec 08 Feb 09 Feb 09 Feb 09 Mar 09 FDA accelerated approval EMEA Market authorisation Health Minister says top-ups not allowed NICE negative final guidance protest from 26 academic oncologists DH review backs top-up payments NICE draft guidance approves 1st line only newspaper protest at unfairness NICE permits 2nd line use after IFN final guidance due 8 9 10 Bevacizumab (Avastin) - colon cancer 11 NICE - Lapatinib (Tyverb) breast cancer Feb 07 Mar 07 Apr 07 Jan 08 Jun 08 Sep 08 Nov 08 Jan 09 May 10 final scoping study FDA NDA passed closing date for evidence 1st appraisal meeting EMEA market authorisation 2nd appraisal meeting 3rd appraisal meeting 4th appraisal meeting expected guidance 12 Ratio of E13: UK and TOP COUNTRY: UK DRUG 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 13 Cost per QALY inflation 14 Cancer funding UK per PCT Centre for Health Economics, York, 2007 M&C Cancer Network: PCT spending on cancer Spend (£ Millions) per 100,000 Unified Weighted Popn Spend on Cancer by PCT 2004-5 9.0 England Average 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 Bebington & West Wirral Ellesmere Port And Neston South Sefton Know sley St Helens North Liverpool Birkenhead & Wallasey Cheshire West Southport and Formby South Liverpool Central Liverpool Warrington West Lancashire Are you ill? No Have you got cancer? Yes No Yes Have you got medical insurance? Yes NHS oncologist is willing and able to prescribe the most effective drugs? Check the cover. Some insurers are beginning to limit benefits No Prepared to self fund? Yes No Purchase drugs for oncologist to administer on NHS Remain an NHS patient No Legal challenge – There is no legal reason as to why patients cannot top up their NHS care No Purchase a second opinion until Yes No Yes Is the drug available in England, Scotland, Wales or Northern Ireland Yes No take up residence? Complain to the Chief Executive of Hospital (copying the Healthcare Commission) Complain to local PCT It is generally accepted that the majority of cancer sufferers who challenge their PCT win Yes Survive on NHS Win 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 Survive on NHS Yes Win No Survive on NHS Fail Yes Win No Survive on NHS Fail Write to your local MP If your case goes to the PCT Exception Committee and it is declined – challenge the decision and the authority of its members Make cancer charities aware of your challenge – they can be a mind of information 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 17 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 18