Professor Richard Sullivan, you’re the Cancer Policy and Public Health Professor at Kings College, London but here in Lyon at the meeting of National Cancer Institute Directors you’re talking about the value of cancer care for society. I’ve got to put a simple question, that’s a big topic but how have you been summing it up?
The framing of value for cancer care in society is quite complicated. People automatically think of just money, the economics of cancer care but it’s much more than that. It’s about actually the principles of how we want to deliver cancer care into society, the principles of solidarity, the principles of equity and the principles of justice in terms of access to equal treatment and diagnosis for all cancer patients. So we’re trying to frame it in a very broad holistic manner, both for high income countries and for emerging economies.
And it’s an issue of whether we are enriching society by giving good cancer care and when especially this has to be compared with care in other aspects of our lives. So what’s your pitch?
The issue here is about the trade-offs. In high income countries we have to deal with all non-communicable diseases and so good cancer care has to be put into the context of good care for dementia, for people with heart disease, because cancer doesn’t sit alone. So that’s one issue but when you look at emerging economies and other countries outside high income, they’re in a completely different ball game. These are countries with what we call a quadruple burden of disease – communicable diseases, non-communicable, HIV/AIDs and in many countries still interpersonal problems.
So it’s even more complicated. Let’s start with the rich countries though. Is it a question of getting enough money for cancer and what does that money and the funding and the organisation do to enrich society in rich countries? What is it?
The first issue is that the proportion of money that goes into cancer care is not directly correlated with the outcomes. We know up to a certain level we do need a certain amount of money but after that actually you can get laws of diminishing returns. It’s not just simply a question about money, it’s how the care is organised, it’s the attitudes of the healthcare professionals and, indeed, the policies which frame cancer care.
And from your studies I must ask you for one or two recommendations about framing cancer care optimally.
One of the first big recommendations we’ve made is we have to deliver affordable cancer care and that means very good outcomes for good value quality. What we’re seeing increasingly is technologies coming in which are adding less and less to patient benefit but costing more and more. So policies need to address that.
How do you cope with all of this in a commercial society where there are lots of companies who need to sell their products who are offering all sorts of things? How do doctors and indeed patients balance what they actually need and what they don’t?
There are huge commercial pressures now to deliver new technologies very quickly into society where they haven’t been properly tested. So the first thing is the bar for getting a technology into society to begin with has to be set relatively high. And secondly we do have to have health technology assessment programmes, we have to know what technologies are cost effective or not.
So you need a National Institute for Clinical Excellence and similar bodies in technology just as much as for drugs?
Absolutely, not just for drugs but for surgical techniques, biomarkers, all forms of care. This is going to become increasingly important with the pressures of the economics.
OK, let’s move over to low and middle income countries. We’ve been hearing some horror stories here at the meeting in Lyon of National Cancer Institutes’ Directors about countries where there just is virtually no proper plan for cancer management and cancer care.
There’s a huge issue. First of all to have a national cancer plan the country has to be functioning anyway. So you have to have a healthcare system which functions.
But many of these countries function very well in other areas like infectious diseases. What needs to be done and what can be done for cancer?
Two things: first of all there has to be a recognition that non-communicable diseases and cancer are important and many senior policymakers still don’t believe it’s an important area. Secondly national cancer planning in these countries has to be fit for purpose. They have to start driving institution to institution relationships, to improve the care and control in those countries and they also have to start working on developing affordable care systems. Most emerging economies and low income countries will simply never be able to cope with the expense of the technological burden we have at the moment in high income countries.
You need to operate a form of triage to deliver the right care to the people who can benefit from it rather than spending resources and time on all patients which simply might not be possible. That’s very difficult to put into place, isn’t it?
It is and I think we haven’t been innovative and imaginative enough. For instance, we’re not doing enough to build on existing infrastructures that have been put in for HIV/AIDS and all sorts of other communicable diseases. There’s real win-win benefit to be built here actually starting to put non-communicable disease infrastructure onto communicable disease and allowing the two to leverage across each other. Because we’ve essentially had policies where there’s too much clear blue water between these two areas and there needs to be much more integration.
What, then, would be your guidelines to politicians to help them make the right priorities?
Firstly, make health in your country a strategic priority. Number two is focus on the areas of greatest need where it cuts across.
I’m sure they’re saying they’re doing that already, so what’s going wrong with cancer?
Particularly what’s going wrong with cancer is it’s just not high on the political radar and the advocacy movements within particular countries are often quite low down. This makes it very fragmented and difficult to deal with things.
So getting up and shouting about it is important but how should you shout? What sorts of things should you be shouting about?
The first thing is to actually advocate for non-communicable diseases and cancer as whole. It’s very difficult in many of these countries just to simply take one particular disease area, you have to advocate for the whole movement. So that’s one particular and, secondly, actually finding long-term sustainable relationships with other institutions in high income countries can be a huge help to leverage your position in your country and make politicians realise how important the particular disease is and, secondly, that solutions are available if you work in partnership with other people.
So give us a brief take-home message then.
The really key message, really, that we’re trying to put across is cancer is going to have increasing impact on countries across the globe, major economic impact, particularly in areas where they’re most sensitive to in terms of women’s health, and countries need to start addressing that burden now using partnerships, existing infrastructure for HIV/AIDs and coming up with imaginative solutions to the burden for the future.
Richard, thank you very much.