15th Congress of the European Hematology Association (EHA), 10—13 June, 2010, Barcelona

Interview with Dr Paul Cornes (Bristol Oncology Centre, UK)

The role of clinicians in cost-effective cancer treatment

So here at the EHA, you’ve been speaking about health economics and the cost of cancer treatment, specifically as cancer is projected to be the major killer in 2010, what are the implications of what you’ve presented today?

Well the implications of that is that there’s going to be up to 27 million patients with cancer diagnosed each year by 2030; it’s going to be the world’s biggest health problem. And so we’re not going to just have an increase in the numbers of cancer patients, which would be a burden on our health service enough, but also all the advances we’ve heard at these meetings tell us that there’s more and more we can do, we’re going to spend more on each patient themselves.

And we’ve learnt already that the budget for cancer medicine is outstripping other branches of medicine. We’re using more and more resources, and we’ve had a decade of steady increases in funding to represent those advances. But few of us can have missed the fact there’s a credit crunch, and many of the delegates at this European meeting are telling us already that they’re facing real cuts in their health budgets for next year, and they’ve got to make savings.

So what can we do? We know a bit about NICE in the UK. How can we learn from that on a global level?

NICE is hugely influential and most people don’t realise that although it’s seen as a rationing body, it’s actually about balancing the competing claims for that pool of scarce resources. And already there are eight European countries with a body like NICE or something similar to it, and a couple more that have roles close to it. And they’re doing something very important: they’re trying to assure access to healthcare by all the population. That’s kind of rational uses of resources. And although it seems fashionable amongst doctors to knock NICE, if we don’t take control of that situation ourselves, we’re going to have it forced on us.

We know in America that spending on cancer medicine has increased about five-fold over the last decade, whereas spending on drugs for other branches of medicine has gone up only about 50%. And it puts us very much in the spotlight when the accountants look at our hospitals, we’ve actually got to take control.

I think you can do it, there’s no doubt that we can be much more cost-effective in our treatments - how many cycles of chemotherapy you give, who’s actually most appropriate for it. When there’s a choice of regimens, we should think not only what’s the most clinically effective drug, we’ve got to start saying what’s cost-effective as well. We are quite prepared to pay more for expensive drugs. Some of these new advances, most of them seem to come from biotechnology, and those are very expensive drugs to develop. But they’ve paid back handsomely in terms of increased survival and quality of life and length of life.

The only way we’ll know whether an expensive drug is better than a cheap drug is through a formal health technology evaluation, cost-quality studies, as NICE does it. And I think we’re all going to have to get better at reading those articles, working our own hospitals to bring up guidelines, each individual doctor can do it, but also helping nationally. If doctors aren’t involved in this research we shouldn’t be surprised then, when it’s imposed on us from outside.

So doctors have to start thinking about economy, they have to think about how much drugs cost and is it the best drug for the patient. Do you think an individual doctor will start to do this?

I’m sure they will. There’s a survey that was looked at in 2009, that asked doctors, compared to last year, are you now taking cost into consideration when you decide treatment for a patient? The answer is about half of all oncologists asked now consider it far more than they did just one year ago. Now that was 2009, when our budgets weren’t in big pressure. If you ask it at this meeting now, I suspect it will be way more than half. So I think we’re all going to have to take control of it, or it will take control of us.

ecancer thinks that this is a key area for people also working on economics of drugs and health, so people that are interested in sending papers on these projects, we would very welcome them.

I think it’s absolutely crucial, isn’t it, that most of us are now very skilled at reading clinical outcome papers. If I come at this meeting and present a randomised trial and claim survival advantages, my colleagues will know a lot about different randomisation methods, the statistics we use, whether we’ve chosen the right end points, and I won’t get away with something that isn’t really accurate. And there’s a feeling that when a health-economic presentation is made, that somehow it belongs to the economists and not to the doctors; and therefore it’s okay not to try and understand it.

And that’s why as part of the EORTC we’ve been running courses and for the anaemia group, which is about supportive care in cancer, for the last four years one of our components every year in the teaching course has been how to read health economic papers and understand them. At the end of this we’ve actually got a whole list of free-to-read papers that you can download for yourself off of websites that we’ve put ready for the session here at EHA and you’re very welcome to have that on the website here for other people to use.

Just to show that the cancer societies have taken it seriously, in 2009 one of the major goals of the ASCO, American Society of Clinical Oncology meeting, was individualised care and health economics. In the ASH meeting, the American Society of Haematology, this winter, I’m going to be with my colleagues from Canada and America in one of the 90-minute spotlight sessions, where again we’re hoping to press home this message, that doctors can learn how to read these papers, can play their part, and I think your point about getting them published is important. If they’re published in an area that doctors will read it, rather than a health economics journal, we’ll all begin to take control. And if the mainstream doctors’ cancer media is interested, I think it’s good for us all, so well done.