Wednesday, July 27, 2016
Malaysia - It's time to increase drug options for patients
WHEN it comes to cancer, many healthcare professionals advocate early detection as this can greatly increase the chances of the treatment being successful.
Although there are no Malaysia-centric statistics on the number of patients whose cancer is diagnosed late, research has shown that almost 50 per cent of patients in the United Kingdom who get cancer are diagnosed late, making treatment less likely to succeed and reducing their chances of survival.
What this means is besides a greater need for education on early detection and screening, we need to ensure that patients with late diagnoses can access treatment and that their quality of life following diagnosis is not compromised. An example of a cancer that is often diagnosed late is renal cell carcinoma (RCC), also known as kidney cancer.
This is because the symptoms for RCC — such as loin pain, fever, weight loss and even bleeding in urine — are similar to that of other diseases and may surface only in the late stages of RCC. In fact, 49 per cent of patients in Malaysia are diagnosed with RCC when the cancer is at the final stage (Stage IV).
A study conducted at the University Malaya Medical Centre showed that the five-year survival rate of patients with Stage IV RCC was only 13 per cent. Kidney cancer is among the 10 most frequently occurring cancers in Western communities.
Globally, about 271,000 cases of kidney cancer are diagnosed yearly and 116,000 people die from it. According to the Malaysia National Cancer Registry Report published in 2007, the incidence of RCC is 0.6 per cent in Malaysian females and 1.7 per cent in males. RCC accounts for 43.8 per cent of new kidney cancers reported in Malaysia in 2007.
However, these statistics present limitations as it has been nine years since the data was collected for the registry. In addition, the actual statistics might be higher as data collection and reporting for RCC in rural areas can be challenging and lead to under-reporting.
Oncologists estimate that the incidence is most probably higher based on the increased number of RCC patients they have been consulting.
Despite the doom and gloom of cancer statistics, all is not lost. Advancements in medical research have led to new forms of treatment being developed for patients.
In the past, treatments with chemotherapy have not been effective and led to disappointing results. New treatment options, in the form of targeted therapy, emerged as a tool to fight cancer cells with more precision and potentially fewer side effects.
Revisions in healthcare policy should ideally be aligned with innovation in cancer treatment. Despite new targeted therapies being approved for use by the authorities in the United States and Europe, these are still limited in most parts of Southeast Asia, including Malaysia.
Even if they are available in the market, patients have to buy the drugs from private medical facilities as not all of them are funded by the government. This excludes a large number of Malaysians from accessing it in the public or government sector.
According to the National Health and Morbidity Survey 2015 (NHMS 2015), more than two-thirds of the adult population preferred government to private facilities when seeking healthcare services for major health problems, minor and major surgery, dental treatment and for child delivery.
Furthermore, a higher proportion of those in rural areas, the lower socio-economic groups and the aged population (above 75) preferred government healthcare facilities. When it comes to seeking treatment for major illnesses, the proportion of respondents preferring government hospitals increased to 75 per cent.
Thus, there is a pressing need for more drug options to be made available in public hospitals so that more patients benefit from the treatments. In the case of treatment for RCC or kidney cancer, there is only one drug approved and listed in the government formulary.
More options are needed by patients and clinicians because a single drug may not be suitable as every individual has different needs.
For patients who are not able to respond to this particular treatment, access to an alternative drug will allow them to continue treatment.
However, access to an alternative drug is often a lengthy and uncertain process. For some patients, the options that are available are so dismal that it is almost a case of no option at all. This is a grave injustice to patients because it is not available at the facility where they seek treatment. This can force patients to pick treatments that merely address the symptoms and not the cause of their condition or seek treatment at healthcare facilities that may be priced out of their reach (that is, private hospitals) just to obtain the right drug and treatment.
In Western or developed countries, the options to these drugs are fully funded by the government, leading to patients having equal access to treatment drugs that best suit them. However, in Malaysia, drug choices are limited and patients are left with limited or no options.
Patients may have to pay out-of-pocket expenses to access other treatment but this will put them in a difficult financial dilemma of cost versus survival. In fact, a recent study showed that five per cent of cancer patients and their families were pushed i nto poverty in Southeast Asia between March 2012 and September 2013. The study, which was published by Dr Nirmala Bhoo-Pathy from Universiti Malaya’s Faculty of Medicine, evaluated data collected in eight low- and middle-income Southeast Asian countries, including Malaysia.
The study also showed that cancer resulted in “financial catastrophe” for almost half of the patients who suffered from economic hardship at the time of diagnosis. The policy of approving new drugs is based on an analysis of the quality of life years patients gain versus the cost of the drug.
Unfortunately, drug affordability is determined by pharmaceutical companies based in developed countries such as the US and Europe. This leads to a mismatch in drug affordability in a country like Malaysia, where people have a diverse range of economic situations.
Therefore, no matter how clinically effective a drug is touted to be, due to a mismatch in affordability criteria, no drugs have been approved in the government formulary in recent years. In the foreseeable future, cancer is set to be a major burden worldwide and become the leading cause of morbidity and mortality.
Although the good news is that there are new innovative products being approved by health authorities, cost still remains a major issue. Patients are often tormented with the choice between survival and cost, something that patients in Western countries do not have to contemplate as their treatments are fully funded by their health authorities.
Thus, it is imperative for policy- makers to review and update the targeted cancer therapy treatments in the national formulary. The last time an innovative drug indicated for solid tumours was listed was in 2013. The formulary is updated and made available at least three times a year and we urge the health authorities to provide similar targeted treatments for kidney cancer patients.
These targeted treatments may have higher costs but they have been proven to be efficacious and improve survival rates of patients. For better treatment outcomes in patients, the Health Ministry should ensure that medicines with proven efficacies are accessible to the majority of the population.
We hope that more funding will be made available to assist patients in their treatment so that they can live longer with better quality of life without putting them at risk of financial catastrophe. Malaysia’s healthcare system has been recognised by the World Health Organisation as one of the best among the 37 member states.
While the public delivery system continues to undergo transformation to meet the needs of a growing and ageing population as well as alarming rate of non-communicable diseases, let us be aware of the imperative need for Malaysia to keep abreast of breakthrough therapies that impact patient survival and quality of life and to champion for these therapies to be accessible in public hospitals.
Cancer does not discriminate. Every patient, regardless of economic status or whether he or she is at the early or end stage, deserves access to treatment.
Datuk Dr Mohd Ibrahim Abdul Wahid
Datuk Dr Mohd Ibrahim Abdul Wahid, medical director, Beacon International Medical Centre, and vice-president, College of Radiology, Malaysia