/ 2 November 2012

Prevention still better than cure

The high cost of drugs is putting them out of patients' reach
The high cost of drugs is putting them out of patients' reach

Progress against cancer is stalling, with the latest targeted cancer drugs failing to live up to expectations and priced so high that treatment is becoming unaffordable, even in rich countries, according to experts at a meeting of nearly 100 eminent cancer specialists from around the world.

At the gathering, in Lugano, Switzerland, the doctors agreed on a 10-point declaration, to be published early next year, that will chart the way forward for cancer care around the globe. Much needs to be done, they believe, to improve treatment, care and prevention both in the developed world and in poor countries, where cancer rates are rising even faster. They agreed to embark on an ambitious plan to get essential cancer care to those who are dying early in developing countries, in the same way as  Aids doctors took on the fight to get HIV treatment into Africa.

The meeting of the World Oncology Forum, organised by the European School of Oncology and attended by experts such as epidemiologists Sir Richard Peto and Professor Michel Coleman, agreed that urgent action was needed.

Only a few years ago many cancer experts thought the arrival of targeted medicines designed to attack the genetic make-up of the tumour would make dramatic inroads into cancer deaths. But the excitement generated by targeted drugs, which interfere with specific molecules involved in tumour growth and suppression, has been short lived.

Doctors reported apparently miraculous results from the use of the BRAF-inhibitor vemurafenib in advanced malignant melanoma, a usually fatal form of skin cancer, said Douglas Hanahan of the Swiss Institute for Experimental Cancer Research. Within two weeks the tumours melted away. "But six months later, [the cancer] is back with a vengeance," he said.

Other drugs working in a similar way – including erlotinib (Tarceva) for a form of lung cancer, bevacizumab (Avastin) for breast, colorectal and other cancers and sunitinib (Sutent) for renal cell carcinoma and gastrointestinal sarcoma – had also not done so well, said Hanahan. Resistance to the drugs built up, sometimes very quickly. "All came on line with great expectations. The reality check is they are all working in the important first step, but we have a long way to go in terms of winning the war."

The future is probably to use these drugs together or in combination with other, older types of drugs, but the price is likely to be prohibitive. A year's treatment with vemurafenib alone would cost £91 000. No health service will be able to afford to put a patient on two or three such drugs at the same time.

Doctors at the meeting said pharmaceutical industry prices were unsustainable – and the pursuit of profits stopped companies taking part in trials of combinations of their drugs with those of their competitors. They were also said not to be interested in testing their drugs combined with older drugs whose patents had expired.

Professor Alexander Eggermont, general director of the Gustave Roussy Cancer Institute in France, said the "economic models of molecular medicine are very uncertain, because if you do not produce cures, you do not know if it is going to sell".

Decades ago, genuine breakthrough drugs were discovered. Peto said that five years of tamoxifen reduced mortality in most breast cancer sufferers by a third and the bene­fits continued even after a woman stopped taking it. And it appeared that taking it for 10 years was even more effective. Nobody knew why resistance did not develop, as it did with the new drugs, he said.

Health management
But the meeting agreed that although changes were needed in research, regulation and funding to speed up progress on new drugs for intractable cancers, a great deal had to be done now to tackle cancer in less well-off countries.

"The divide is such that in Canada almost 90% [of children with leukaemia] can hope to survive, while in the poorest countries of the world 90% are expected to die," said Professor Felicia Knaul, director of the Harvard University global equity initiative. Between a third and a half of all cancers – 2.4-million to 3.7-million cases a year – were preventable, she said, and 80% of those were in lower- and middle-income countries. Preventing and treating them would offer potential productivity savings globally of more than $130-billion a year – far more than the cost of treatment.

Cheap vaccines and basic screening can prevent and detect cervical cancer, which kills young women and mothers. Cheap hepatitis B vaccination protects against liver cancer and screening picks up breast cancer early. The dire shortage of morphine and other opioid drugs in developing countries to relieve suffering from cancer pain had to be addressed, the doctors said.

Rifat Atun, professor of international health management at Imperial College's business school in London, called on doctors and scientists to follow the lead of clinicians involved in the Aids response.

"Prevention is important and we need to do it. That does not mean we should not be providing treatment," he said. A decade ago, people said it was not possible to get antiretroviral drugs to patients with HIV in Africa. There are now more than eight million people in lower-income countries on them. – © Guardian News & Media 2012