The WHO essential medicine list (EML) is a comprehensive, freely accessible, online database containing detailed medicine information with a comprehensive evaluation of effectiveness, safety, and implications for healthcare systems. The EML helps all countries by identifying essential medicines that all patients should have access to, at all times, and should be affordable as well. The basic guideline of WHO EML is that cost should not hinder with accessibility of any medicine, if the said medicine is known to make a substantial difference to population health; hence, the WHO EML serves as a guide to policymakers to implement policies relevant to improving access to these expensive medicines.1

With a global shift from communicable diseases to non-communicable diseases and in particular, cancer, there has been a rapid innovation in cancer therapies. However, all these targeted therapies are accompanied with high costs and modest efficacy. Most of these newly launched cancer medicines cost more than $100,000 USD per year. Therapies like CAR T-cell therapy may cost up to almost $500,000 USD per year.2 It is also seen that costs of these medicines may not correlate with the value of the medicine in terms of efficacy; hence, practising oncologists may not necessarily concur with the selection of cancer medicines in the EML. There is thus a need to understand if oncologists across the globe concur with the cancer medicines suggested in the WHO EML and the availability and accessibility of these medicines in all countries.

An electronic survey3 was conducted using a global network of practising oncologists via 80 country-level contacts and two regional networks – one from Latin America and the Caribbean Society of Medical Oncology and other from sub-Saharan Africa. A total of 948 respondents from 82 countries (low and lower middle, upper middle, and high-income countries) participated in this survey. About 75% of the respondents were medical oncologists and 17% were clinical oncologists. Respondents from low-income and lower middle-income countries majorly prescribed chemotherapy and radiotherapy (39%) than those from upper middle (17%) and high-income (8%) countries.

The top 20 cancer medicines considered as high-priority medicines by the respondents were cytotoxic drugs (60%) and targeted therapies (20%) followed by immunotherapies and hormonal therapies (10% each). The most commonly selected medications included doxorubicin, cisplatin, and paclitaxel followed by pembrolizumab, trastuzumab, and carboplatin (Figure 1). More than 75% of the selected medicines were common across all the income groups. However, recent therapies like immunotherapies were not listed by respondents of the low-income and lower middle-income countries, while respondents of the other two income countries listed these (pembrolizumab and nivolumab) along with recently developed hormonal treatments. The availability of these medicines also varied between the low-, middle-, and high-income countries (Figure 1). Dexamethasone was the only medication that was regarded as universally available by more than 50% of respondents from low and lower middle-income countries. There was a substantial risk of catastrophic expenditures for these medications in the low and lower middle-income countries (13–68%) versus the upper middle-income (2–41%) and high-income countries (0–9%). The proportion of respondents indicating universal availability of each top 20 medications was 9–54% in low-income and lower-middle-income countries, 13–90% in upper-middle-income countries, and 68–94% in high-income countries. The respondents in the high-income countries suggested that patients had access to almost all the medicines except for some out-of-pocket expenses for drugs like osimertinib and imatinib.

The results of this study suggest that while WHO EML provides guidance on priority medicines, this is not prioritized in country-level policies, thereby limiting access to these essential medicines to all patients uniformly. The access is further limited due to the affordability of these medicines. As a result of this, while healthcare providers across the world concur on high-priority cancer medicines and how cancer should be treated, there is a divide in clinical practice in the real world. Immunotherapies and targeted therapies are prescribed majorly only by oncologists in high-income countries. Access to health is the fundamental right of all patients irrespective of the income level of the country. Thus, there is a serious need for oncologists across the world to intervene and demand the availability of priority interventions and essential medicines for all their patients. Only then, appropriate policies focussing on integrated solutions will be developed by policymakers to make priority medicines accessible and affordable for all cancer patients.

References:

1. https://www.who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines/essential-medicines-lists

2. Leighl NB, et al. An arm and a leg: The rising cost of cancer drugs and impact on Access. Am Soc Clin Oncol Edu Book. 2021;41:e1-12.

3. Fundytus A et al. Access to cancer medicines deemed essential by oncologists in 82 countries: An international, cross-sectional survey. Lancet Oncol. 2021;22(10):1367-77.