Challenges in using new lung cancer drugs in Asia Pacific

Shobha Shukla and Bobby Ramakant, CNS (Citizen News Service)
Lung cancer is the most common cancer worldwide, and especially in the Asian-Pacific region, is a major public health problem. In 2012, there were an estimated 1.8 million new lung cancer cases (13 percent of all cancers diagnosed), and 1.59 million deaths (19.4 percent of the total cancer deaths). Despite many recent advancements in the treatment of lung cancer, there are challenges in the use of novel regimens.

An equity issue?
Dr Michael Boyer

Dr. Michael Boyer, a member of the APLCC 2016 Committee and on the IASLC Board of Directors, shared the perspective of Australia. He is also the Professor of Medicine at the Sydney Cancer Centre, and Chief Clinical Officer of the Chris O’Brien Lifehouse in Australia. IASLC Asia Pacific Lung Cancer Conference (APLCC 2016) is being held in Chiang Mai, Thailand and CNS (Citizen News Service) is the official media partner of APLCC 2016.

“There are two main challenges for Australia. The first is concerning our national system, whereby new drugs are first made available in the local market and then approved by the government for cost reimbursement. So, there could be a time gap of 6-12 months between the marketing approval of a new drug (when it is available in market but too costly for people to buy) and its reimbursement approval,” Dr. Boyer said. “Currently all targeted therapy drugs are available and also reimbursed. The problem is with immunotherapy drugs like Nivolumab, which currently is sold in Australia but is not reimbursed. So, one has to buy it from one’s own pocket. However, the government’s reimbursement decision for this drug is awaited.”

Dr. Boyer calls this “an equity issue where some people can and some cannot afford the new drugs till they are approved for reimbursement. So, it would be great to streamline the Australian system to shorten this time delay between marketing and reimbursement approval for new drugs.”

“The second challenge is about education of patients and doctors to ensure that the patients get the right drugs at the right time. But this problem has largely been dealt with in Australia, even though it may be present in other countries. Patients on immunotherapy drugs should be well informed so that they are able to recognize the side effects and do the right things to get treated well. Patients involved in clinical trials get very familiar with the use of drugs and they play a crucial role in educating others. As immunotherapy drugs in Australia were approved even before they were used for lung cancer treatment, many oncologists already have experience with them and do not face any particular challenge in using them for lung cancer treatment,” he said.

Are drugs beyond reach for those most in need?

Dr. Virote Sriuranpong, Associate Professor, Department of Medicine Chulalongkorn University in Thailand and Co-Chair of APLCC 2016, listed the high cost of medicines as a major problem.

While there can be a better prognosis in patients through access to the novel medicines, Dr. Sriuranpong said, “The new medicines are unaffordable for many people. Thailand is a developing country and the average income is low to moderate. It takes a few years before any new medicine gets approved to be marketed in the country. Hence, most of the patients may not be able to access them until the generic medicines come out and this could take as long as five to 10 years after approval.”

He gave the example of the new oral tyrosine kinase inhibitor (TKI) drugs Gefitinib and Afatinib, which bring about positive results in lung cancers with EGFR (epidermal growth factor receptor), mutations that are quite prevalent in Asian countries, including Thailand. These drugs, though available in Thailand, are very expensive.

“As of now, only Thai government officers and their families (who constitute just 10 percent of the total population) are entitled to cost reimbursement for these drugs. So, the majority of the patients either have to pay out of pocket or are not able to access them. However, costs of all basic medicines to treat cancer, including chemotherapy drugs, are covered by the universal health coverage. Immunotherapy drugs like Nivolumab – used in second-line settings for patients with advanced squamous cell carcinoma – are currently not available in Thailand,” Dr. Sriuranpong said.

Dr. Sriuranpong said, “Thailand needs to not only get good access to medicines, but also find suitable ways to ensure that all the patients, including those most in need are able to access these medicines.”

Does cost block access to new medicines?

Dr. Purvish M. Parikh, Director of Precision Oncology and Research at the Asian Institute of Oncology, Somaiya Hospital, Mumbai, India, agrees that to treat an incurable cancer with expensive medicines is a big challenge in the Southeast Asia region because most countries are low and middle income countries. Whether the patient takes treatment from a government or a private hospital, there are cost-related issues.

“Targeted therapy for lung cancer treatment is being used in India and other countries in Southeast Asia. New oral drugs, like TKIs, can significantly improve median survival of metastatic lung cancer patients with promising results, and appropriate use would benefit a large number of patients. Now, there is more information about mutations (like EGFR, BRAF and ALK) and genetic changes that take place in lung cancer, and this helps in selecting the right drugs for the right subset of patients. So, with an increase in the number of drugs and improved molecular profiling, doctors are more precisely able to identify the most appropriate drug for a particular patient,” Dr. Parikh said.

Dr. Parikh shared that there are several schemes in India to help patients who cannot afford the high cost of treatment.

“The government provides up to INR 0.15 million (USD $2,250) for the cancer treatment of a poor patient. There are also patients’ assistance programmes where medicines are provided free of cost or at discounted rates by pharmaceutical companies. Some charitable trusts and NGOs also provide financial aid to such patients. A few lung cancer drugs are available as cheap but quality generics,” he said.

He hopes immunotherapy drugs will soon get marketing approval in India too, where they are currently available only to some patients. Those patients have benefitted immensely, remaining well and alive for several years.

Dr. Parikh is hopeful that in the future, with improved understanding of lung cancer and the combination of drugs to use, cure rates for lung cancer will go up and it will become a chronic, if not curable, illness.

Establishing a global genomic screening system

Dr Nagahiro Saijo, Japan
Dr. Nagahiro Saijo, Chief Executive Officer of Japan Society of Medical Oncology, and member of the APLCC 2016 International Committee, gave an overview of Japan’s contributions, (home to many clinical trials) for the development of molecular therapy drugs and immune checkpoint inhibitors in lung cancer treatment.

“At this moment, about 70 molecular target drugs have been approved, 41 of which (including 22 small molecules and 19 antibodies) are available in Japan. Five molecular therapy drugs have been developed in Japan: HDAC inhibitor Rodipepcin; MEK inhibitor Trametinib; ALK inhibitor Alectinib; anti-PD-1 antibody Nivolumab; and anti-CCR4 antibody Mogamulizumab,” he said.

“We are finding many mutations in lung cancer. Lung cancer should be reclassified into various genomic subtypes, and drugs for each tumour type should be developed. For this purpose, establishment of nationwide/global genomic screening system will be mandatory. Japan’s ‘Lung Cancer Genomic Screening Project for Individualized Medicine’ is one such effort. Based on innovative technology for gene analysis, we now believe that ‘one-size fits all’ medicine should be converted to precision medicine. Genomic screening for the identification of the driver gene will be crucial to the development of new drugs to improve lung cancer treatment outcomes in the future,” Dr. Saijo said.

Shobha Shukla and Bobby Ramakant, CNS (Citizen News Service)
15 May 2016