By Guest Author 17/02/2016

by Dr Francis Hunter

Reminiscent of the furore surrounding public access to a one-year course of Herceptin, PHARMAC’s recent assignment of a low funding priority to pembrolizumab (Keytruda) for advanced melanoma has brought cancer drug funding back to the centre stage of national debate.

Obfuscation from health minister Jonathon Coleman notwithstanding, the plight of metastatic melanoma patients in New Zealand is real, urgent and well-documented. The single drug that is funded for these patients, dacarbazine, is a 1970’s relic that provides marginal, if any, medical benefit.

Yet, the intensive focus on just one drug for one disease risks obscuring the broader pharmaceutical funding challenges that New Zealand faces;   challenges that will only amplify in the coming years.

Access denied

Despite the controversial findings of PHARMAC’s commissioned report comparing cancer drug funding in New Zealand and Australia, there is little doubt among medical oncologists and cancer scientists that New Zealanders cannot access many state-of-the-art cancer medicines through our public healthcare system.

Pembrolizumab is just one of 22 new drugs approved by the U.S. Food and Drug Administration (FDA) in 2014-2015 for treating cancer (the full list is given below). The majority of these will not be funded by PHARMAC in the foreseeable future.

New cancer drugs approved by the FDA

blog table 1

Commentators have correctly pointed out that many modern oncology drugs command very high prices yet only extend life by several months. Cancer drugs have indeed become very expensive – a subject to be covered in later editions of this blog – yet the funding debate needs to be informed by an understanding that using several, incrementally effective drugs in series is one means by which cancer will eventually be transformed from the deadly disease of the 20th century to a chronic disease of the 21st.

Pembrolizumab itself is currently only approved for advanced melanoma and (in the U.S.) for a certain type of lung cancer. However, it is undergoing clinical testing for 30 different tumours including every one of the 20 most common cancers in New Zealand (which are ranked by incidence in the table below).

Dollars vs desire to benefit

We do not yet know which of these cancers can be effectively treated with pembrolizumab, and not all patients will meet the criteria to receive the drug. As with any new drug approval, eligibility will depend on factors such as the type of cells that make up the tumour, the stage of disease, sites of active metastasis, prior treatments and genetic or molecular features.

Yet the future is eminently clear – we are approaching an impasse between dollars available and our desire to benefit from the fruits of long labour in cancer research.

Case in point, late last year Medsafe approved Imbruvica (ibrutinib) for treating chronic lymphocytic leukaemia, the most common form of blood cancer. Whether to fund this expensive yet effective drug presents PHARMAC with yet another difficult decision.

Cancer cases in New Zealand – by type

blog table 2

Forcing PHARMAC to permanently fund pembrolizumab – or any other specific drug – by executive action of cabinet, as initially proposed by Labour health spokesperson Annette King, is certainly the wrong response. This approach ignores the fact that a near-identical drug, nivolumab, is soon to become registered and should be considered. A peloton of further immunotherapy medications is in close pursuit.

More importantly, PHARMAC has certainly been a value-accretive vehicle for New Zealand, and political interference in the drug selection process might not improve overall health outcomes. Their funding decisions are difficult to fault given the resources appropriated to them by successive governments. An early access scheme is a worthwhile proposal to relieve the patients who are unfortunate enough to develop cancer while new drugs make the slow march through full evaluation, but such an initiative can only defer tackling the more fundamental question.

Is PHARMAC systemically underfunded?

By comparison, the Republic of Ireland, which is almost identical to New Zealand in terms of population and GDP, funds a number of high-cost cancer drugs that we do not. In 2014, Ireland spent €1.8bn ($3bn) on drug access, while in the same year PHARMAC was given just $795mn.

PHARMAC’s Pharmacology and Therapeutics Advisory Committee (PTAC) is an appropriate instrument for appraising the cost-benefit profile of new medicines, but it is all of our collective responsibility for deciding the value that we place on investing in first-world cancer treatment in New Zealand.

Dr Francis Hunter is the John Gavin Postdoctoral Fellow at the Auckland Cancer Society Research Centre, University of Auckland