Cancer Medicines Availability Analysis

This report investigates the availability of medicines used in the treatment of cancer in Aotearoa New Zealand (Aotearoa). In this report, ‘available medicines’ means medicines that are publicly funded in Aotearoa via Pharmac. The report describes the findings of an analysis that compares the availability of cancer medicines here with that of Australia – not only in terms of the number of medicines funded, but also in terms of clinical benefit.

Cancer medicines are a crucial part of the treatment of many different types of cancer – both solid tumours and blood cancers. Better cancer outcomes are more likely to be achieved when there is equitable access to effective medicines. People with cancer, and the people caring for them, rely on cancer medicines. They expect that when they need a cancer medicine, it will be available.

It is also important to recognise that the public funding of cancer medicines is a complicated issue. New medicines are being developed at a rapid pace. On the one hand, this provides much needed hope and options for people with cancer. On the other hand, the rapid pace of development and the high cost of cancer medicines can make it difficult for governments worldwide to assess what added clinical benefit new medicines offer and how much of finite public funds should be allocated towards new cancer medicines, relative to other needs that also require public funding.

In Aotearoa, Pharmac is the government agency responsible for deciding which medicines to fund across all areas of health, while the Government is responsible for deciding how much is allocated to medicines funding. Pharmac has a relatively unique approach to medicines funding compared with other countries. It is generally evident that there are fewer cancer medicines publicly funded in Aotearoa compared with other high-income countries with similar health systems, such as Australia. This difference in funding is a very real concern for people with cancer, their whānau, and the people and organisations caring for them.

Te Aho o Te Kahu is responsible for providing leadership and oversight of all aspects of cancer control in Aotearoa, from prevention through to diagnosis, management and beyond. In our work we often hear people’s concerns regarding cancer medicines availability. The purpose of this analysis was to help us better understand the gaps in the availability of cancer medicines in Aotearoa, a particularly complex area of cancer care.

To understand the gaps in cancer medicines funding in Aotearoa, we compared the medicines that are currently publicly funded here with the medicines publicly funded in Australia. We looked at the number of medicines, as well as the specific cancers they are funded to treat. When identifying gaps, we linked together the medicine with the specific cancer type where it is used-we called these medicine-indication pairs. It was important to do this because certain medicines can be used to treat many different types of cancer, so just looking at the medicines alone would not tell the full story.

To assess the clinical benefit associated with any identified gaps in funding, we used an internationally recognised tool – the European Society of Medical Oncology – Magnitude of Clinical Benefit Scale (ESMO-MCBS). This scoring tool considers evidence from clinical trials of medicines for solid tumours, using measures such as survival and quality of life. Using this tool allowed us to distinguish between medicine-indication pairs that are likely to provide substantial additional clinical benefit over and above the medicines already funded in Aotearoa, and medicine-indication pairs that are likely to have less clinical benefit. Because the tool is only validated for medicines used to treat solid tumours (ie, not medicines for blood cancers), we have only been able to fully assess the situation for solid tumours at this time. We plan to conduct a similar analysis for medicines used to treat blood cancers, as soon as a similarly validated tool to assess clinical benefit becomes available.

The ESMO-MCBS is designed to inform policy decisions on cancer medicines, rather than specifically inform clinical decisions at an individual level. We acknowledge that what this tool defines as substantial clinical benefit may, in many cases, be different to what is considered meaningful to an individual patient and their whānau.

For those gaps with an ESMO-MCBS score indicating substantial clinical benefit, we sought expert clinical advice to confirm the relevance of the score to Aotearoa and describe how filling the gap would alter current clinical practice here.

We identified 20 different medicine-indication pair gaps, across nine different solid-tumour cancer types, where the medicines were publicly funded in Australia and not in Aotearoa, and where the ESMO-MCBS score indicated that the medicine would offer substantial clinical benefit. This does not mean that 20 different medicines would need to be funded to fill these gaps; the number of unique medicines was actually 18. This is because there was some overlap of the medicines that could be used, some medicines must be used in combination, and in some cases, there was more than one medicine to fill a gap.

Three of the 20 medicine-indication gaps were in the curative context, entailing five unique medicines. For these gaps, the medicines are used alongside surgery with the intent to cure, to reduce the possibility of the cancer from coming back after it has been removed. One of these gaps was for a medicine used in a specific type of breast cancer, and the other two were for two specific types of melanoma.

The remaining 17 medicine-indication gaps (entailing 17 unique medicines) were in the non-curative context. For these gaps, the medicines are being used with the intent of either extending a person’s life, or improving the quality of their life, or both. In these treatment settings it is not expected that the cancer will be cured. These gaps were for medicines used across eight different cancer types: lung (five gaps), bowel (two gaps), liver (one gap), kidney (three gaps), bladder (one gap), ovarian (two gaps), head and neck (one gap), and melanoma (two gaps).

For each of the 20 identified gaps, we described the clinical context and population-level epidemiology (such as how many people are diagnosed with the cancer, survival rates and existing inequities). We described what additional health service requirements might be needed if the gaps were funded, such as extra imaging. We also included what additional things patients might need to consider, such as more time receiving treatment or more blood tests. The gaps were all for targeted cancer medicines rather than for traditional chemotherapy. Some of these medicines are given by infusion and mean extra health care resources are needed and patients may have additional travel requirements. Others are tablets and could free up health care resources. Some have specific side-effects that are quite different to traditional chemotherapy and require specialised management.

We also looked at whether these gaps were currently within Pharmac’s processes for assessment, and, if so, where in that process they were. Many of the gaps are either under active assessment, or have already been assessed for funding by Pharmac and are now ‘Options for Investment’ – that is, awaiting available funds to be made available in Aotearoa. Since the time of our analysis, two of the identified medicines have been approved for funding by Pharmac: durvalumab for a certain type of lung cancer, and olaparib for a certain type of ovarian cancer.

Additional gaps were identified for medicines used in the treatment of blood cancers. These were not assessed for clinical benefit due to the absence of a validated assessment tool.

The analysis presented in the report is our first step in better understanding this important issue of gaps in cancer medicines funding. The detailed gap analysis was necessarily limited to solid tumours, and we plan to conduct a similar analysis for medicines used to treat blood cancers once a validated tool – like the ESMO-MCBS – is available to assess clinical benefit in blood cancers.

By identifying and describing gaps in cancer medicines for solid tumours, together with the relevant context, we hope to provide useful insights to Pharmac, the New Zealand Government, the health sector and to the public. This analysis was conducted separately to the independent review of Pharmac announced by the Government in March 2021, but preliminary results of this analysis were shared with the Pharmac Review Panel.

The findings of this analysis are important to help optimise the role that cancer medicines play in improving cancer control in Aotearoa. Cancer medicines are an integral part of cancer care. However, cancer medicines do not and should not exist in isolation. The full benefits of cancer medicines can only be realised if the whole spectrum of cancer care – from early detection through to diagnosis, staging, treatment, follow-up and supportive care – is working well and equitably, and if there is adequate workforce to deliver all aspects of cancer care, including medicines. Strengthening the cancer continuum as a whole remains the key objective for Te Aho o Te Kahu, and is essential to deliver on the goals of fewer cancers, better survival, and equity for all.