In the countries that form the Association of South East Asian Nations (ASEAN), cancer is a disease that is sometimes overlooked. The national health strategies of these countries are often focused on communicable or metabolic diseases but like almost everywhere around the world, the impact and burden of cancer is on the rise alongside steadily aging societies, urbanization and a change in lifestyles. There were over 18 million new cases of cancer globally in 2018, including over 2 million cases in North America, over 4 million in Europe, and approximately 1 million in ASEAN.
The role of innovative medicines in cancer care
Although the number of people diagnosed with cancer is rising, innovative cancer medicines along with better care are both helping cancer patients to live longer and with a better quality of life. Over the past decades, mortality rates of many cancers have reduced. In the 1970s, fewer than half of the people with cancer survived five years. Today, two out of three people diagnosed with cancer survive at least five years. Approximately 73 percent of survival gains in cancer can be attributed to new medicines.
Better treatment and improved survival rates mean patients are able to maintain or return to their usual daily routines, resume work, and play an active role in society and the economy. Cancer treatment has evolved from pain palliation to chronic management. Targeted therapies can stop or slow down disease progression, minimize complications, prevent hospitalizations and surgeries, reduce side effects, and, in the best cases, even provide curative options. Improving access to new, innovative medicines can further improve treatment outcomes and relieve the impact of cancer on patients and society.
The widening care gap between ASEAN and developed economies
Cancer policies of ASEAN not only differ in comparison to developed Western economies, but we also see varying policies due to individual healthcare systems in each member country. There are gaps in knowledge and awareness of the disease among the general public, lack of alignment in care priorities and delivery infrastructure, as well as a lack of early diagnosis and in enhancing treatment outcomes. In particular, there is little uniformity when it comes to access to innovative cancer medicines, leading to delays and disparities for patients across ASEAN.
In some countries, reimbursement frameworks are inefficient and decision processes are slow, impeding the effective use of medicines among clinically eligible patients and ultimately resulting in a substantial loss of life years.
Furthermore, we see disparities in health plans that do not – or only partially – cover the provision of cancer drugs, while some price control mechanisms and policies can also result in restricted patient access. Consequently, some patients find themselves having to pay all expenses out of pocket, despite the majority not having sufficient funds to cover their treatment.
On the occasion of the UICC World Cancer Congress 2018 in Kuala Lumpur, this health policy article takes a look at Malaysia, Thailand and Vietnam and how access to cancer treatments differs across the three nations. We have focused on one of the more common cancers in ASEAN, hepatocellular carcinoma (HCC), the most common type of liver cancer worldwide. According to the latest official statistics from GLOBOCAN 2018, liver cancer is the sixth most prevalent cancer worldwide, with the highest incidences being observed in Asian countries.
Like most developed and advanced developing countries, Malaysia is seeing an upward trend in the prevalence of non-communicable diseases (NCDs) such as cancer and cardiovascular disease. Cancer persists as one of the five main causes of national mortality over the past 20 years and the number of cases has since escalated. In 2015, cancer contributed to 13.6 percent of all deaths in Ministry of Health hospitals compared to 8.9 percent in 1996.
A need for access to innovative medicines
In Malaysia, there is good access to traditional cancer treatments such as surgery and chemotherapy. However, for patients who do not respond to these treatments, the access to cutting-edge, innovative cancer medicines including targeted therapy, precision therapy and other new treatment paradigms is limited, placing cost burden on patients and their families.
Liver cancer is the sixth most common cancer in Malaysia
The annual mortality rate for liver cancer per 100,000 people was 6.1 percent in the year 2013, an increase of 42.8 percent since 1990. This is due in part to a lack of understanding of the disease. Hepatitis B virus (HBV) remains the leading cause of HCC in Malaysia. However, Hepatitis C virus (HCV) infections are increasingly playing a role in the development of the disease and are expected to continue to rise in the coming years. One concern is that many of those infected with HBV or HCV are unaware of their status and, coupled with the limited availability of effective treatment options, could explain the rising numbers of patients presenting with HCC.
Slow reimbursement processes in Malaysia impede patient access
Even though treatment options are available in the earlier stages of HCC, the survival rate is generally very poor as the majority of patients present at a very advanced stage. For those patients who are waiting for liver cancer treatment in Malaysia, the therapies needed are not available in the official list of prescribable medicines, resulting in patients having to obtain the medication elsewhere via an extremely slow process. This unfortunately means that for many, the cancer advances too far to be treated – some patients even die before receiving their medication.
Thai health policy has a strong focus on the prevention and treatment of infectious diseases, despite the growing rate of patients suffering from cancer and other NCDs. NCDs account for 71 percent of mortality in Thailand, of which cancer accounts for the second largest proportion at around 17 percent. According to the World Health Organization (WHO), the cancer mortality rate in Thailand in 2012 was 127.8 per 100,000 for men and 82.6 per 100,000 for women - the fifth highest in the Southeast Asia region.
HCC liver cancer is the most common type of liver tumor in Thailand
Approximately 60 percent of the cancer burden in Thailand is due to five types of cancers and liver cancer is one of them. Half of Thai patients affected by HCC have a chronic HBV infection; cirrhosis is also a common underlying disease. Unfortunately, patients often present in the advanced stages of HCC and thus have mostly poor treatment outcomes.
Limited access to innovative medicines impedes treatment
Notably, Thailand has been successful in implementing a Universal Health Coverage (UHC) system. Since 2002, 98 percent of the Thai population is covered by health insurance and the country has seen significant improvements in health outcomes for patients. However, cancer patients still have limited access to innovative therapies, the majority of treatments being traditional treatments such as surgery or chemotherapy. Only a small number of Thai patients are eligible for the reimbursement of innovative medicines, meaning that most may need to pay entirely out-of-pocket for such treatments.
Although Thailand has a good medical infrastructure in place and specialists that are on-par with international standards, there remains inequitable access to oncologists and tertiary centers, with coverage dictated by payer scheme and geography. Even though there is a willingness to pursue new access mechanisms to increase patient access to innovative medicines with high clinical value, the current budget and policy priorities constitute substantial barriers to more widespread access.
Non-communicable diseases represented 47 percent of total mortality in Vietnam in 2002, with 8.2 percent due to cancer. The leading cancers are lung, liver, stomach, colorectal and nasopharynx for men, and breast, cervix, and stomach and liver for women. The country has implemented initiatives to help tackle the growing number of cancer incidences, addressing problems such as a lack of early screening and putting an emphasis on public knowledge of the disease.
Though the capacity for cancer diagnosis and treatment has been strengthened significantly in Vietnam, the effectiveness of treatment still needs greater support in term of guaranteeing access to medicine and advanced treatment techniques. The cost of cancer treatment is actually higher than the long-term ability to pay for the majority of Vietnamese population.
Reducing hepatitis B burden to help prevent liver cancer
In 2012, the WHO estimated that Vietnam was one of the countries with the highest mortality rates from liver cancer, which is mostly attributed to the sheer number of people infected with hepatitis B virus (HBV) and hepatitis C virus (HCV).
Thus far in Vietnam there has been no comprehensive nationwide approach to HBV and HCV-related liver diseases, including HCC. The universal HBV vaccination program for infants started in 2002 however, unfortunately, the coverage of HBV vaccination has fluctuated and in 2013 coverage was reported to have dropped to under 60 percent. Therefore, to reduce the burden of HBV and HCV-related liver diseases, it is crucial to increase the coverage of the universal HBV vaccination for infants as well as promote other preventive measures against horizontal transmission of both HBV and HCV.
Lack of reimbursement a prohibitive barrier to patient access and treatment
Though the capacity for cancer diagnosis and treatment has been strengthened significantly in Vietnam, treatment efficacy still needs greater support in terms of guaranteeing access to medicine and advanced treatment techniques. For the majority of Vietnamese, the cost of cancer treatment is actually higher than their long-term ability to pay. This calls for a widespread insurance policy to answer the need for more equitable access in the country.
Advocating for better cancer care in ASEAN countries
As we have seen in the examples above, there are multiple barriers to the effective prevention and treatment of cancer in some ASEAN countries. It is vital that new, innovative cancer drugs reach patients in ASEAN countries who are in need. With the incidences of cancer predicted to continue increasing, and to improve the current standard of care, ASEAN countries would need to:
- invest in early diagnosis and increase the number of specialized cancer centers;
- build comprehensive cancer databases to better understand both effective treatment of the disease as well as patient needs;
- remove access delays and barriers to innovative cancer therapies for patients. There should be at least one first-line treatment for liver cancer accessible for clinically-eligible HCC patients;
- establish dedicated cancer care funds either within the national health budget, insurance system, or as a new part of the national health budget;
- explore cooperation with stakeholders that are involved in cancer care.
Public and private healthcare sectors in ASEAN countries along with the support of non-governmental organizations must collaborate more strongly to improve access to innovative oncology medicines in the region. This, in tandem with measures such as improving cancer awareness, prevention and early diagnosis, will effectively relieve the cancer burden in ASEAN, ultimately benefitting patients and society.