Currently, cancer is likely to occupy the center stage on any discussion related to the fastest growing therapy segments in the pharma or biotech industries. There are several reasons behind such probability, some of which include:

• Cancer is not only the second leading cause of death globally, but also offer outstanding new drug treatment options, though, mostly to those who can afford.

• Consequently, these drugs are in high demand for saving lives, but not accessible to a vast majority of those who need them the most.

• Alongside, oncology is one of the fastest growing therapy segments in sales in many countries, including the largest and most attractive global pharma market - the United States.

• New cancer drugs being complex, involves highly sophisticated cutting-edge technology – creating an entry barrier for many, and are generally high priced, fetching a lucrative profit margin.

These are only a few basic dynamics of the segment. Nevertheless, understanding these dynamics, in a holistic way, is indeed an enigma – caused mostly by directly conflicting arguments on many related issues, within the key stakeholders. Thus, I reckon, this issue will be an interesting area to explore in this article. Later in this discussion, I shall try to substantiate all the points raised, backed by credible data. Let me start with some causative factors, that may make comprehensive understanding of the dynamics of this segment enigmatic.

Some causative factors for triggering the enigma:

Close overlap of several contentious factors is associated with this head-scratcher. These come in a package of reasoning and counter reasoning, a few examples of which may be seen below:

• When increasing incidence of cancer related deaths are a global problem, fast growing oncology segment, regularly adding novel drugs in its portfolio, ideally should be a signal for containing this problem. Whereas, the World Health Organization (W.H.O) reports, cancer drugs are beyond reach to millions, for high cost. Nonetheless, the cancer drug sales keep shooting north.

• Nearer home, while Indian anti-cancer drug market growth has, reportedly, ‘outstripped that of all other leading countries in recent years and is set to go on doing so,’ another study report underscores, ‘Indians have poor access to essential anti-cancer drugs.’

• Although, a 2019 report of W.H.O highlights: Expensive cancer drugs ‘impairing’ access to cure, innovator companies also have their counter argument ready. They claim, higher prices ‘are necessary to fund expensive research projects to generate new drugs.’

• When innovator companies keep touting that many new therapies are path-breaking concepts, researchers don’t find these drugs much superior to the existing ones in outcomes, except jaw-dropping prices.

• Despite the above argument of research-based drug players to justify unreasonable pricing, several studies have established that the development cost of new cancer drugs is more than recouped in a short period, and some companies are making even more than a 10-fold higher revenue than R&D spending.

• While several pharma companies claim that they are providing patients with access to a wide variety of cancer medication through Patient Assistance Programs (PAPs), the findings of several published research on the same concluded, ‘the extent to which these programs provide a safety net to patients is poorly understood.’

Let me now briefly substantiate each of the above points raised in this article.

Incidence of cancer and the oncology market:

Now, while substantiating the above points, let me go back to where I started from. According to the W.H.O fact sheet of September 12, 2018, cancer is the second leading cause of death globally and is responsible for an estimated 9.6 million deaths in 2018 – about 1 in 6 deaths was due to cancer. Approximately 70 percent of deaths from cancer occur in low- and middle-income countries. The Indian Council for Medical Research (ICMR) estimated around 1.4 million new cancer cases in 2016, which is expected to rise to 1.7 million cases by 2020.

According to ‘World Preview 2019, Outlook to 2024’ of Evaluate Pharma, ‘Oncology prevails as the leading therapy segment in 2024, with a 19.4 percent market share and sales reaching USD 237bn.’ The report also highlights: ‘Oncology is the area with the largest proportion of clinical development spending with 40 percent of total pipeline expenditure.’

Similarly, the Indian Oncology market is found to be growing at 20 percent every year and is likely to remain so for the coming 3-5years. In 2012 the cancer market was valued at USD 172m (quoted from Frost & Sullivan). Another report also reiterates, the oncology market in India has outstripped that of all other leading countries in recent years and is set to go on doing so.

Poor access to cancer drugs:

Despite the impressive growth of oncology segment, ‘high prices for cancer medicines are “impairing the capacity of health care systems to provide affordable, population wide access,” emphasizes a recent ‘Technical Report’ of W.H.O. I shall further elaborate on this report in just a bit. However, before that, let me cite an India specific example of the same. The March 2019 study, published in the BMJ Global Health, also highlighted, the mean availability of essential anti-cancer medicines across all hospitals and pharmacies surveyed in India was less than the WHO’s target of 80 percent.

Cancer drug pricing conundrum:

The recent ‘Technical Report of W.H.O – ‘Pricing of cancer medicines and its impacts’ confronts this issue head on. It clearly articulates, the enduring debates on the unaffordability of cancer medicines and the ever-growing list of medicines and combination therapies with annual costs in the hundreds of thousands, suggests that the status quo is not acceptable. The global community must find a way to correct the irrational behaviors that have led to unsustainable prices of cancer medicines. Thus, correction of unaffordable prices is fundamental to the sustainability of access to cancer medicines. Further inertia on this issue and half-hearted commitments from all stakeholders, including governments and the pharmaceutical industry, will only invite distrust and disengagement from the public, the report emphasized.

Another 2019 WHO report says expensive cancer drugs ‘impairing’ access to cure. It pinpointed: “Pharmaceutical companies set prices according to their commercial goals, with a focus on extracting the maximum amount that a buyer is willing to pay for a medicine.” It also reiterated that the standard treatment for breast cancer can drain 10 years of average annual income in India. Unaffordable pricing of cancer medicines set by such intent often prevents their full benefits being realized by scores of cancer patients, the report adds. Yet another paper expressed similar concern about ‘the unsustainability of the high costs of cancer care, and how that affects not only individual patients, but also society at large.

What does the industry say?

The industry holds a different view altogether. According to another recent news, one such company quoted their 2017 Janssen U.S. Transparency Report,” which states: “We have an obligation to ensure that the sale of our medicines provides us with the resources necessary to invest in future research and development.” This is interesting, as it means that even higher pricing may be necessary to fund expensive research projects to generate new drugs for life threatening ailments, such as cancer.

What do research studies reveal?

There are several research studies often disputing the industry quoted claim of R&D spend of over a couple of billion dollar to bring a new molecule to the market. They also keep repeating, this is an arduous and time-intensive process, involving humongous financial risk of failure. One such ‘Original investigation’ titled, ‘Research and Development Spending to Bring a Single Cancer Drug to Market and Revenues After Approval,’ published by JAMA Internal Medicine in its November 2017 issue, presents some interesting facts.

The study brings to the fore: ‘The cost to develop a cancer drug is USD 648.0 million, a figure significantly lower than prior estimates. The revenue since approval is substantial (median, USD 1658.4 million; range, USD 204.1 million to USD 22 275.0 million). This analysis provides a transparent estimate of R&D spending on cancer drugs and has implications for the current debate on drug pricing.’ Thus, the cost of new cancer drug development is more than recovered in a short period, with as much as over 10-fold higher revenue than R&D spending, in many cases, as the analysis concluded.

Even top oncologists, such as Dr. Peter Bach, the Director of Memorial Sloan Kettering’s (MSK)Center for Health Policy and Outcomes, along with other physicians at MSK drew attention to the high price of a newly approved cancer drug. According to available reports, ‘two recently approved CAR-T cell drugs – one is USD 373,000 for a single dose, the other USD 475,000 - are benchmarks on the road to ever-higher cancer drug price tags.’

It happens in India too:

Although, on May 19, 2019, NPPA announced almost 90 percent price reduction of nine anti-cancer drugs, curiously even those cancer drugs, which are not patent protected, continued to be sold at a high price. For example, according to the September 2018 Working Paper Series, of the Indian Institute of management Calcutta (IIM C), the maximum price for Pemetrexed, a ‘not patented’ cancer product was Rs 73,660, though, it is also available at Rs 4,500. Similarly, the price of Bortezomib was between Rs 60,360 and Rs 12,500 and Paclitaxel between Rs 19, 825.57 and Rs 7,380.95. It is intriguing to note that no pricing policy for patented drugs, as promised in the current Drug Policy document, hasn’t been implemented, as yet. 

Does Pharma’s ‘Patient Assistance Programs (PAPs) work? 

Different pharma companies claim their addressing access to cancer care in developing countries. A report also mentions: ‘16 of the world’s largest pharmaceutical companies are engaged in 129 diverse access initiatives in low- and middle-income countries.’ Whereas, a research study, questioning the transparency of these initiatives, concluded, ‘our results suggest that numerous drug company sponsored PAPs exist to provide patients with access to a wide variety of medications but that many details about these programs remain unclear. As a result, the extent to which these programs provide a safety net to patients is poorly understood.’

During the famous Glivec patent case, which went against Novartis at the Supreme Court of India, the company’s PAP for Glivec in the country, also came under focus. Many articles, with mutually conflicting views of the company and independent experts were published regarding this program. One such write-up emphasized with eulogy, “Novartis provides Glivec free of charge to 16,000 patients in India, roughly 95 percent of those who need it via the Novartis – Glivec International Patient Assistance Program. The remaining 5 percent is either reimbursed, insured, or participate in a very generous co-payment program. Thus, not granting a patent for Glivec really hasn’t prevented patients from getting this life-saving medication.”

However, many were, reportedly, not convinced by Novartis’ claims and counter-argued: “Our calculation says there are estimated 20,000 new patients every year suffering from cancer, this means after ten years there will be two lakh (200,000) patients, hence the program is not enough.” The views of many independent global experts on the same are not very different. For example, even Professor Carlos M. Correa had articulated: “The reported donation of Glivec by Novartis to ‘eligible patients’ under the ‘Glivec International Patient Assistance Program’ (GIPAP) may be a palliative but does not ensure a sustainable supply of the product to those in need.” Be that as it may, new studies now question whether novel anti-cancer drugs are worth their extra cost.

Are novel cancer drugs worth the extra cost?

According to a September 26, 2019 report, the results of two studies investigating the links between clinical benefit and pricing in Europe and the USA, reported at the European Society for Medical Oncology (ESMO) Congress, September 2019, reveal an interesting finding. It found, many new anti-cancer medicines add little value for patients compared to standard treatment and are rarely worth the extra cost. Interestingly, in the midst of this imbroglio, the world continues taking a vow globally to mitigate the cancer patient related issues on February the fourth, every year.

A vow is taken globally on every 4^th February, but…:

On every February 04 – The World Cancer Day - an initiative of the Union for International Cancer Control (UICC), the world takes a noble vow. Everybody agrees on its broad goal that: ‘Life-saving cancer diagnosis and treatment should be equal for all – no matter who you are, your level of education, level of income or where you live in the world. By closing the equity gap, we can save millions of lives.’

UICC also noted, as many cancers are now preventable or can be cured, more and more people are surviving the disease. However, for the vast majority people, the chances of surviving cancer are not getting better. Socioeconomic status of individuals leaves a significant impact on whether one’s cancer is diagnosed, treated and cared for, in an appropriate and cost-effective manner. A customer-focused understanding of the dynamics of the cancer therapy segment, although may help effective ground action, but the status quo continues for various critical reasons. Even on the World Cancer Day 2019, the oncology pricing debate continued.

Conclusion:

The business dynamics for the cancer therapy segment, continues to remain enigmatic regardless of public emotion and sentiments attached to these drugs. Patients access and affordability to the most effective drug at the right time can save or take lives. Surprisingly, despite healthy growth of anti-cancer drugs, especially the newer and pricey ones, the number of deaths due to cancer is also fast increasing, and is the second largest cause of death today.

The pricing conundrum of cancer drugs remains the subject of a raging debate, globally. Nevertheless, the drug industry keeps justifying the mind-boggling prices, with the same sets of contentious reasons, even when various investigative research studies negate those claims. Moreover, when general public expects the drug industry to innovate both in the new drug discovery and also on making the drug prices affordable to a large section of the population, the industry doesn’t exhibit any interest to talk about the latter. Instead, they talk about PAP initiatives for improving access to such drugs. Notwithstanding independent research studies concluding that PAPs lack transparency, and is not an alternative for all those who want to fight the disease, in the most effective way.

The arguments and counterarguments continue. More effective cancer drugs keep coming with lesser number of cancer patients having access to those medicines, as patents prevail over the patients. The reverberation of the power of Big Pharma to stay in the chosen course – come what may, can also be felt from the reported statement of politically the most powerful person in the world – the President of the United States. In view of this, both the business and market dynamics of the cancer therapy segment is likely to remain enigmatic – at least, in the foreseeable future?

By: Tapan J. Ray   

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.