Cancer treatment and care: a new and uneasy world

Abstract

World Cancer Day, an annual aide-mémoire about the multifaceted burden imposed by cancer on the world's people and societies, fell on Feb 4. For decades hopes have been high that investments in intensive research would transform the diagnosis and treatment of cancer, and in various types of malignancy progress has been dramatic. However, despite the efforts of doctors, researchers, and taxpayers, cancer remains a looming and elusive target. Improvements in life expectancy have increased not only an individual's lifetime risk of cancer but the geographical imprint of the disease. In the UK, the World Cancer Research Fund predicts a 30% increase in new cancer diagnoses to 396 000 per year by 2030, with expectations elsewhere grimmer still. And we must expect more of the same—there will be no letup in the growing spectre of cancer in developed and developing countries, in the increasing demand for effective and affordable treatments (as well as compassionate care) for people with cancer everywhere, or indeed in economic constraints and concerns about equity. The UK's National Institute for Health and Clinical Excellence (NICE) has recently announced frustrating draft guidance recommending against general provision of abiraterone, a new drug that could be beneficial as part of the treatment for men with metastatic castration-resistant prostate cancer. Abiraterone is an interesting test case for the issues involved in availability of new medical treatments, especially in the UK where some of the drug's development took place. Prostate cancer is common in men yet the course of the disease is difficult to predict. Abiraterone has been shown to be capable of extending life by about 4 months on average. Some 3300 men in the UK would hope to be treated with the drug each year, which could cost in the region of £35 000 for an annual course. In NICE's study, cost-effectiveness estimates exceeded £60 000 per quality-adjusted life-year, and it is the perceived low ratio of clinical benefit to financial cost that has led to NICE's recommendation. For British men with advanced prostate cancer there remains hope that abiraterone might be available to them, given the provisional nature of NICE's guidance and the annual £200 million cancer drugs fund that is available for such treatments for patients in England. Although not all malignancies raise the same challenges for screening and diagnosis as those posed by prostate cancer, in a recent Morbidity and Mortality Weekly Report Carrie Klabunde and colleagues discuss implications of the 2010 National Health Interview Survey for cancer screening in US adults. Individually reported screening for breast, cervical, or colorectal cancer suggests coverage in 2010 of 72·4%, 83·0%, and 58·6% respectively, falling well short of targets set for 2020 (of 81·1%, 93·0%, and 70·5% coverage). The survey reveals unsatisfactory inequalities in cancer screening, with Asian Americans, for example, less likely to report screening for all three diseases, and lower levels of screening for colorectal cancer reported by black Americans. Unsurprisingly, level of education was positively associated with reported breast cancer screening, and screening rates were substantially lower in uninsured Americans. It is to be hoped that the Patient Protection and Affordable Care Act being phased in by the current US administration will remain on course to harmonise health-care provision throughout the USA and diminish such health inequalities. Thinking of the future, we sense oncological needs and expectations growing beyond what can be planned or provided for fairly. A drug like abiraterone, promising benefit in an area of evident clinical need, will have taken 20 years and substantial funds to develop. Early stage drug development is likely to have been undertaken by researchers with charitable or public funding, with the translational and clinical research by commercial entities leading, in abiraterone's case, to indelicate public haggling over how much 1 year of an average patient's life is reasonably worth. In the UK, it is perhaps time for a change in regulatory emphasis by introducing greater flexibility into our notions of cost-effectiveness. Different price limits for different diseases could then serve to encourage research and drug development in areas of unmet need. Identification of patients more likely to benefit from drugs will also grow in importance. In the developing world, abiraterones can largely be ignored for the period of their patent protection, and patients must make do with the treatments that their doctor or health system can provide. Disease prevention and screening, meanwhile, need to receive higher priority, in both rich and poor settings. To paraphrase the slogan for World Cancer Day—together, it needs to be made possible.