The coronavirus (COVID-19) pandemic has put a spotlight on health system resilience around the world. Demands on health care provision have skyrocketed in record time and brought some health care systems to the brink of collapse. Public funds to purchase testing equipment, protective equipment, and later on also vaccines were cleared quickly. This resolute prioritization by governments has been estimated to have saved millions of lives (Watson et al. 2022). Compared to COVID-19, cancer is a long-term challenge for health care systems. No lockdowns can stop or slow the emergence of cancer incidences.
Cancer and population aging in Asia
In Asia, the annual number of new cancer cases increased from 4.9 million in 2002 to 9.5 million in 2020 (Parkin et al. 2005; Sung et al. 2021). Until 2040, projections by the International Agency for Research on Cancer estimate 15.1 million new cases per year. The key determinant of this development is population aging, which is taking place at an unprecedented rate across the region, causing a surge in the numbers of elderly people. It is, therefore, no surprise that Japan, the country with the oldest population in the world, has the highest rate of cancer (Hung et al. 2021).
Outcomes of cancer patients differ greatly across Asia
High-income countries with higher proportions of older populations, such as Japan or the Republic of Korea, face much higher cancer numbers than middle-income countries with higher proportions of younger populations such as India and Indonesia. However, this pattern is reversed for the survival of cancer. In the wealthier countries of the Asia and the Pacific region, such as Australia, Japan, and the Republic of Korea, around 56–65 in every 100 new patients survive cancer, whereas in the developing part of the region only around 28–40 in every 100 new patients survive (Hofmarcher et al., 2021).
Challenges to improving the outcomes of cancer patients
Explanations for the poor showing of middle-income countries in Asia can be found in all areas of cancer care. Early detection of cancer cases can greatly improve the chances of a curative outcome. In Asia, early detection is hampered by low awareness of the early signs of cancer among the general population and the absence of or low participation in screening programs, such as for breast cancer (Wang et al. 2022).
Universal access to standard cancer therapies and care is another pressing challenge. Several of the most basic cancer medicines listed on the World Health Organization’s Model List of Essential Medicines are not listed on national formularies in lower-middle-income countries and low-income countries in Asia (Enui et al. 2019). Therefore, cancer patients in these countries incur full out-of-pocket costs for some generic, inexpensive medicines, while all of these medicines are readily available in the high-income and upper-middle-income countries in Asia (Enui et al. 2019). These country differences are even larger for the subset of newer higher-priced cancer medicines that are characterized by a substantial clinical benefit (“innovative cancer medicines”). On average 68% of the said innovative medicines approved by the Food and Drug Administration in the United States are on national formularies in high-income countries compared to 17% in middle-income countries in the Asia and Pacific region (Hofmarcher et al. 2021).
The root cause of these challenges is underfunded health care systems and the absence of universal health coverage. Despite being a centerpiece of the United Nations Sustainable Development Goals 2030, universal health coverage is still to be achieved in many countries in Asia. Apart from access to health care services, what matters is also the quality of the services. There is a massive gap in annual investment in public health care, with investment of less than $100 per capita in countries such as India, Indonesia, the Philippines, and Viet Nam compared to more than $3,500 per capita in Japan (Hofmarcher et al. 2021).
Implications of inadequate cancer care provision
Cancer patients in many countries throughout Asia face a double burden. On the one hand, poor access and quality of care dashes patients’ hopes of survival. On the other hand, there is a great financial burden on cancer patients and their families. As many as half of all cancer patients and their households in Southeast Asian countries face financial catastrophe from high out-of-pocket medical bills and related expenditures in their first year after cancer diagnosis (ACTION Study Group 2017).
Patients in high-income countries in Asia are incurring losses of life-years running into the millions because of delays to the inclusion of innovative cancer medicines in national formularies. These delays between national approval and inclusion in the national formulary often amount to 1.5–3 years, apart from Japan which has a minimal delay. In middle-income countries, patients often wait 10 years or more for the inclusion in the national formulary, and often this happens only after patent expiry. For a country like Thailand, a 10-year delay of a sample of 10 innovative cancer medicines means over 300,000 life-years lost (Hofmarcher et al. 2021).
Economies also face a heavy impact from not providing adequate cancer care. Premature death, sick leave, and the early retirement of cancer patients, who otherwise would have been working, represent a productivity loss to the economy. Family members who must stay at home and care for the cancer patient instead of pursuing their regular work are another source of loss to the economy. In Europe, it has been shown that productivity losses and informal care costs are just as large as the total health expenditure on cancer care (Hofmarcher et al. 2020).
Achieving a turnaround to meet cancer patients’ needs
The COVID-19 pandemic has created tremendous momentum in the field of health care. However, the long-term challenge for health systems in Asia lies with non-communicable diseases, in particular cancer, spurred by shifting demographics. There is an urgent need to address the growing demands in cancer care.
Cancer medicines can play an important role in meeting the growing demands. The launch of over 100 new cancer medicines over the last decade is a testimony to this. However, not all new medicines are equally effective, calling for the prioritization of truly innovative medicines that bring significant impact to individual patients, their families, and society at large. The inclusion of new medicines in national formularies should be value-based and evidence-based in order to maximize patient outcomes under limited health resources. Health technology assessment is a tool to support evidence-based reimbursement decision-making for inclusion in national formularies, but its use is still in its infancy in many Asian countries.
An overlooked opportunity by governments is to tap into potential savings by stimulating competition between pharmaceutical producers (Enui et al. 2019). With the first wave of modern cancer medicines launched at the turn of the millennium going off patent now, the use of biosimilars and generics instead of the originator medicines deserves greater attention. Generic brand competition and stricter price control of originator medicines after patent expiry could create considerable budget headroom for governments. A published estimation of a basket of cancer medicines with generic brands points to savings opportunities of around 3%–20% of total cancer medicine expenditure in the Asia and the Pacific region, corresponding to over $180 million in the case of Taipei,China and $80 million in Thailand (Hofmarcher et al., 2021). These savings could be re-channeled to fund and list innovative medicines, offering a more sustainable financing model while improving patient outcomes.
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