December 12, 2022

Bowel Cancer New Zealand Position Statement: unfunded medicines

New Zealanders with advanced bowel cancer do not have access to potentially life-extending treatments due to Pharmac’s outdated and inappropriate medicine funding process.

Key messages:

  • Bowel cancer in New Zealand is frequently detected later than it is in other countries, meaning that chemotherapy is often required as well as surgery, and at times chemotherapy and targeted medicines are the only treatment option
  • New Zealand is ranked last out of 20 OECD countries for access to modern medicines, and Australians have funded access to twice as many of these medicines as New Zealanders
  • There have been no new medicines funded for bowel cancer in the last 20 years, despite Pharmac’s advisory committee recommending that bevacizumab be funded in 2010 and cetuximab in 2019
  • The current funding framework has created a two-tier health system that adversely affects cancer patients from lower socioeconomic, Māori and Pasifika communities
  • Pharmac’s decision-making process is outdated and needs to be overhauled in line with the recommendations from the recent Pharmac Review Panel to ensure more equitable access to cancer medicines and better outcomes for bowel cancer patients.

Background

Over 3,000 people in New Zealand are diagnosed with bowel cancer each year, resulting in more than 1,200 deaths annually.1 Due to an ageing population, the number of people diagnosed with cancer is increasing and by 2050 the number of older people diagnosed with bowel cancer will have almost doubled.2 Inevitably, this means that the number of people who need anticancer medicines is also increasing.3

Unfortunately, New Zealanders with bowel cancer tend to be diagnosed later than in other developed countries and one-quarter of diagnoses happen in Emergency Departments.4,5 These patients tend to have advanced cancer and worse outcomes.5 Surgery is the preferred treatment for bowel cancer but in patients with advanced and late-stage disease that has spread to the liver and lungs, chemotherapy and targeted medicines are an important adjunct to surgery or they may be the only realistic treatment option.

New Zealand compares poorly to other countries

Targeted treatments focus specifically on cancer cells and the underlying processes driving their growth, e.g. bevacizumab (Avastin®) and cetuximab (Erbitux®). Despite evidence that they are effective and that Australians with bowel cancer have had access to these medicines since 2009 and 2011 respectively, not a single targeted medicine for metastatic bowel cancer is currently funded in New Zealand.6 There are three principal reasons for this:

1. Medicine purchasing in New Zealand is underfunded
2. The decision-making process is slow
3. There is no overarching strategy for purchasing medicines

Out of 20 OECD countries, New Zealand was ranked last in access to modern medicines.7 The recent review of Pharmac8 and Te Aho o Te Kahu (The Cancer Control Agency) both acknowledge that:9

“…there is no doubt New Zealand lags [behind] other countries in the provision of cancer medicines.”

New Zealand averages 599 days to publicly fund the same medicines that Australia takes 352 days to fund, while the United Kingdom only takes 128 days.7 Furthermore, twice as many modern medicines are funded in Australia as they are in New Zealand, and the United Kingdom funds more than three and a half times as many.7 The result is that New Zealanders with metastatic bowel cancer are not getting medicines that are proven to be life-extending.10–12

The Waiting List

Pharmac is well aware of the effectiveness of the targeted medicines it is refusing to fund. In 2019, the Cancer Treatment Subcommittee (CaTSoP) recommended that cetuximab be funded as a first-line treatment for metastatic bowel cancer.13 CaTSoP said that a “significant benefit was seen” when this class of medicine was added to chemotherapy.13 Te Aho o Te Kahu recently reported that funding cetuximab and panitumumab (Vectibix®) would likely result in significant clinical benefits for approximately 70 New Zealanders with metastatic bowel cancer each year.9 Funding, cetuximab as a first-line treatment for these patients was estimated to result in a survival gain of 8.7 months. However, like many other potentially life-altering medicines, cetuximab sits on the Medicine Waiting List while patients and their families are denied its potential benefits. Bevacizumab was added to the Medicine Waiting List in 2010. The average time on the Waiting List for medicines to be funded in New Zealand is almost 5 years.14

Poor outcomes for Māori and Pasifika

The lack of investment in cancer treatments is contributing to inequity because Māori and Pasifika people are often diagnosed later, with more advanced disease requiring targeted interventions.4,15 Te Aho o Te Kahu points out that the current investment in cancer medicines appears to favour non-Māori/non-Pasifika populations and those living in urban areas.9

Inadequate funding of medicine is one of the reasons why Māori and Pasifika patients with bowel cancer tend to do worse once they have been diagnosed as patients from these communities are often unable to access the newer, non-Pharmac funded medicines. Sadly, the 5-year risk of death following a diagnosis of bowel cancer is 9% higher for Māori and 19% higher for Pasifika, compared to non-Māori-non-Pasifika patients.16

PHARMAC’s decision-making

The reason Pharmac was created was to save money when purchasing medicines from pharmaceutical companies, therefore savings has been the dominant focus for Pharmac.9 Currently, PHARMAC makes decisions on medicine funding by assessing each application against its statutory objective:17

“Does the proposal or decision help PHARMAC to secure for eligible people in need of pharmaceuticals the best health outcomes that are reasonably achievable from pharmaceuticals treatment and from within the amount of funding provided?”

The problem with deciding who is allowed a medicine based on cost, is that it does not account for the price the patient pays in lost time when they are denied treatment. Cost-capped treatment plans are available from medicine manufacturers, but these plans only cover the price of the medicines and not the cost of administering them. Currently, unfunded medicines can only be administered in private hospitals making them even more expensive. The added financial stress is huge and makes the patient’s cancer battle even more difficult.

Pharmac has undoubtedly saved the New Zealand health system millions of dollars. However, as the recent review points out, there needs to be a greater diversity of voices in Pharmac’s decision-making process including patient/carer representatives, Māori and specialists.8

Change is urgently needed

There are currently inconsistencies in Pharmac’s funding decisions for cancer treatments and bowel cancer is the poor cousin. There have been no new drugs approved for treating bowel cancer for over 20 years and this has resulted in significant differences in expected survival between New Zealand and other OECD countries, particularly Australia. The way Pharmac operates has created a two-tier health system where the wealthier patients can afford unfunded medicines, leaving huge inequities between patient groups, specifically affecting lower socioeconomic groups, Māori and Pasifika patients.

Pharmac was recently reviewed for the first time since it was established, 27 years ago.8 Much has changed in cancer treatment during this period and with an aging population and the revolution of targeted therapies, the demand for anti-cancer medicines and their cost has increased.

Bowel Cancer New Zealand supports the findings of the Pharmac Review Panel that found Pharmac needs to be far more integrated into the health system. This means proactively listening to medical oncologists to assess the efficacy of new medicines. Furthermore, the Panel recommended to the Minister of Health that Pharmac’s decision-making framework be improved such that:8

• The cost-benefit analysis for funding medicines is enhanced
• The analysis of equity in funding medicines is strengthened
• Funding decisions make a positive material impact on the lives of patients and their families
• Pharmac’s advisory committees have a greater input into funding decisions
• There is greater clarity at each step of the decision-making process, including what information should be considered when making decisions
• There is stronger oversight by the board of pharmaceutical investment decision-making, with a focus on what is not funded, alongside what is funded

Bowel Cancer New Zealand believes that patients in New Zealand should have access to at least the same standard of care as patients in Australia. This means that Pharmac’s budget needs to be substantially increased so that families are not forced to create “give a little” pages or use their retirement savings to access treatment. The time it takes Pharmac to make decisions also needs to be decreased as cancer patients cannot wait decades for life-extending treatments.

This position statement was created independently by Bowel Cancer New Zealand and was not funded or supported by any external organisations.

References

1. Ministry of Health. Selected Cancers. Published 2016, 2017, 2019 2015. www.health.govt.nz/publication/selected-cancers-2015-2016-2017

2. Pilleron S, Soto-Perez-de-Celis E, Vignat J, et al. Estimated global cancer incidence in the oldest adults in 2018 and projections to 2050. Int J Cancer. 2021;148(3):601-608.

3. Ministry of Health. Cancer: Historical summary 1948-2015. Published 2018. www.health.govt.nz/publication/cancer-historical-summary-1948-2015

4. Blackmore T, et al. Barriers and facilitators to colorectal cancer diagnosis in New Zealand: a qualitative study. BMC Fam Pract. 2020;21(1):206. doi:10.1186/s12875-020-01276-w

5. Ministry of Health. Bowel cancer quality improvement report. Published online 2019. www.health.govt.nz/publication/bowel-cancer-quality-improvement-report-2019

6. The Pharmaceutical Benefits Scheme. Cetuximab, panitumumab and bevacizumab for metastatic colorectal cancer. Published online 2018. www.pbs.gov.au/pbs/industry/listing/participants/public-release-docs/2018-02/metastatic-colorectal-cancer-february-2018

7. Medicines New Zealand. Comparable countries. Published 2018. www.medicinesnz.co.nz/our-industry/comparable-countries

8. Pharmac Review Panel. Pharmac Review: Final report: Executive summary. Published online 2022.

9. Te Aho o Te Kahu. Mārama ana ki te Āputa: he tātari i te wāteatanga o ngā rongoā mate pukupuku i Aotearoa | Understanding the Gap: an analysis of the availability of cancer medicines in Aotearoa. Published online 2022.

10. André T, Shiu KK, et al. Pembrolizumab in Microsatellite-Instability-High Advanced Colorectal Cancer. N Engl J Med. 2020;383(23):2207-2218. doi:10.1056/NEJMoa2017699

11. Van Cutsem E, Köhne CH, et al. Cetuximab and chemotherapy as initial treatment for metastatic colorectal cancer. N Engl J Med. 2009;360(14):1408-1417. doi:10.1056/NEJMoa0805019

12. Rosen LS, Jacobs IA, Burkes RL. Bevacizumab in Colorectal Cancer: Current Role in Treatment and the Potential of Biosimilars. Target Oncol. 2017;12(5):599-610. doi:10.1007/s11523-017-0518-1

13. PHARMAC. Application tracker. Published 2020. https://connect.pharmac.govt.nz/apptracker/s/application-public/a102P000008puV2/p001111

14. Cristine Della Barca. Funding Medicines in New Zealand: Revision of the Medicines Waiting List to 30 April 2020. Published online 2020. www.medicinesnz.co.nz/fileadmin/user_upload/Medicines_Waiting_List_Report_to_30_April_2020_Final__June_2020_.pdf

15. bpacnz. Referral of patients with features suggestive of bowel cancer: Ministry of Health guidance. Published online 2020. https://bpac.org.nz/2020/bowel-cancer.aspx

16. Sharples KJ, et al. The New Zealand PIPER Project: colorectal cancer survival according to rurality, ethnicity and socioeconomic deprivation-results from a retrospective cohort study. N Z Med J. 2018;131(1476):24-39.

17. PHARMAC. Factors for Consideration. Published 2020. https://pharmac.govt.nz/medicine-funding-and-supply/the-funding-process/policies-manuals-and-processes/factors-for-consideration/