Global Trends by Martin Khor

Monday 3 March 2014

Cancer and high drug prices

As cancer cases and deaths shoot up, doctors and patients are outraged by the exorbitant cost of medicines and call for action to be taken


My Global Trends article last week, “A matter of life and death”,  on the effects of the Trans-Pacific Partnership negotiations on the access to medicines for cancer and other diseases was printed on almost the same day as a Star report on the Health Minister’s reaffirmation that Malaysia wants tobacco to be excluded from the TPP.

Datuk Seri Dr S Subramaniam who said that Malaysia had taken a strong stand on the matter was speaking at the opening of the World Cancer Day Conference and Expo 2014.

He said Malaysia’s position (on a tobacco carve-out from the TPP) was “not negotiable from the health perspective as smoking is a clear threat to health.”

The Minister gave some interesting statistics.  Smoking is linked to 20 per cent of all cancer-related deaths. In 2013, the incidence of cancer in Malaysia was 38,000, up from 32,000 in 2008, and this was predicted to increase to 57,000 in 2025.

There were 21,700 cancer deaths in Malaysia in 2012, and on a global scale, cancer had overtaken heart disease as the leading cause of death.

The Minister is right to raise the alarm.  According to a New York Times article, “more people are living into old age and dying of chronic illnesses like heart disease and cancer, which now cause two-thirds of deaths globally”.

“In 2012, there were 14.1 million new cancer cases across the world and 8.2 million cancer deaths, according to the World Health Organization. And the number of breast cancer cases is growing. About 6.3 million women were living with the disease in 2012.”

In response to my article, I received an email letter from Dr. Lim Teck Onn, a private consultant in clinical research, and formerly a Ministry of Health director of the Clinical Research Centre (CRC) network, and consultant nephrologist at the Hospital Kuala Lumpur. 

Dr Lim says:  “I appreciate very much your efforts to bring to the public attention the crucial matter of affordability of life saving medicines, such as your column titled ‘A matter of life and death’ in the STAR yesterday.”

“My own research has shown that much of cancer deaths are avoidable in Malaysia and half are attributable to lack of access to treatment.  You mentioned that Indian companies are ‘leading the fight to make medicines more affordable’.  There are also Malaysian companies engaged in a similar battle.”

Dr. Lim appended the abstract of a journal article he co-wrote with four other Malaysian researchers.  The article estimated the number of deaths due to breast cancer that would be avoidable if all Malaysian patients had access to the care provided by leading centres in Malaysia.

The authors found that of the 2,572 deaths due to breast cancer that was reported by GLOBACAN 2012, 1,299 (50%) were avoidable. Of these avoidable deaths, 647 (50%) were attributable to late stage presentation while 652 (50%) were due to lack of access to optimal treatment.  

“Avoidable premature deaths were high in Malaysia consistent with its high cancer mortality rate,” stated the article.  “Avoidable deaths were equally attributable to lack of early detection and access to treatment.”

Thus, one can conclude from the article that in Malaysia, a significant portion of breast cancer deaths (up to half) could be avoided (or at least the lives could have been prolonged) if there was greater access to treatment.

This brings us to the high price of cancer medicines, and the TPP negotiations.  There is an increasing complaint not only from patients but cancer specialist doctors that cancer drugs are much too expensive, usually more than US$100,000 for a course of treatment for a patient.   

In April 2013, more than 100 cancer specialists from 15 countries around the world signed a joint comment in a journal denouncing the high prices of cancer medicines and called on leading pharmaceutical companies to bring prices down, according to a New York Times article.

Before that, there was a public protest from doctors at a major cancer center in New York, stating they would not make use of a particular brand of cancer medicine for treating colon cancer because it was double the price of another brand. 

Some of the 100 specialists even include researchers with close ties to the pharmaceutical industry.  They specialize in the deadly blood cancer, chronic myeloid leukemia, and in a commentary in Blood, a medical journal, they said that the prices of drugs used to treat that disease are astronomical, unsustainable and perhaps even immoral.

Charging high prices for a medicine needed to keep someone alive is profiteering, akin to jacking up the prices of essential goods after a natural disaster.

“Advocating for lower drug prices is a necessity to save the lives of patients” who cannot afford the medicines, they wrote in the journal.  They also noted that the cost of drugs for many other cancers were just as high.

They gave an example of the medicine Gleevec, used to treat chronic myeloid leukemia.  

The New York Times noted that among the critics is Dr Brian Druker, who was the main academic developer of Gleevec.

The doctors wrote that Gleevec entered the US market in 2001 at a price of about US$30,000 a year, and that since then, the price has tripled even as Gleevec has faced competition from five newer drugs, which are even more expensive.

“If you are making $3 billion a year on Gleevec, could you get by with $2 billion?” Dr  Druker, who is now director of the Knight Cancer Institute at Oregon Health and Science University, was quoted as saying in the New York Times article.   “When do you cross the line from essential profits to profiteering?”  Gleevec’s sales were US$4.7 billion in 2012.

Gleevec became well-known also because the Indian government decided not to grant a patent for the drug because it was not sufficiently “novel”, a decision which was upheld by the Supreme Court.  This opened the way for cheaper generic medicines to be produced.

In fact, there are now several generic medicines for treating various type of cancer being produced and sold in India either because they did not get a patent, or else a compulsory license was issued on a patented drug.  The prices of the generic medicines are a fraction of  the prices of the branded original products, thus making them more accessible to cancer patients.

An Indian company is producing a generic version of Gleevec at the price of US$2,500 for treating a patient a year, down from US$70,000. 

Two companies are producing generic versions of the drug Sorafenib which treats kidney and liver cancers. The original product, named Nexavar, cost US$4,600 per patient per month.  A compulsory license was granted to a local firm to produce a generic version of Sorafenib for US$140 a month, or 30 times cheaper.  

The Indian company Cipla has also produced a generic version of the kidney cancer drug nexavar (although it has been sued for doing so) and a lung cancer drug Tarceva. 

India also rejected a patent application on Tenofovir, a drug to treat AIDS, after opposition to its application was filed by several organisations. Cheaper generic versions are now available.

Another Indian company Biocon has produced a generic version of the breast cancer drug Herceptin.  Due to a challenge by the originator company, its production has been stalled. 

There is a citizens’ campaign on affordable Trastuzumab (which is the non-proprietary name for the breast cancer drug) to make the drug available cheaply.    

There are concerns that the TPP could prevent countries that sign it from taking measures to make drugs more affordable.

In mid-February, eight prominent organisations including Medicins Sans Frontieres, Oxfam, Public Citizen, Health Gap and Knowledge Ecology International, issued a strong statement    on their deep concern about the public health implications of the TPPA.

The new US approach “not only preserves the life-threatening and access-restricting proposals that the US has been pushing since 2011, but also fails to provide adequate recognition of the urgent access to medicines needs of patients living in developing countries.”

Said the groups: “The negotiations must take into account the health needs of all patients living in TPP countries, and the US must halt its efforts to limit countries’ freedom and flexibilities, otherwise the TPPA will jeopardize many, if not millions, of lives”.

The TPP meetings in Singapore last week did not reach any conclusions, either on the patent issue or other contentious issues.

Thus, the fight for countries to retain policy space either for tobacco or for access to medicines continues.