The president of the Indian Society Of Oncology, Dr. Dinesh Pendharkar, agreed with Menghaney. In cancer treatment, every oncologist needs to follow clinical practice guidelines, said Pendharkar.
The most widely followed guidelines globally and in India are written by the national comprehensive cancer network (NCCN) – a US-based not-for-profit alliance of 28 leading cancer centers. But these are supposed to be judiciously used by the oncologist, he added, as every decision involves a human element. The doctor has to understand the context.
What is actually required?
The most important context that an oncologist in India needs to understand is the patient’s ability to pay. The NCCN guidelines, he said, suggest the first and second line of treatment.
If they fail in putting the patient on a clinical trial. But since there are hardly any clinical trials being conducted in India, oncologists’ fall back on prescribing newly-approved patented drugs. Sometimes these drugs fail, sometimes not.
This can prove expensive as the majority of cases of cancer in India are diagnosed at a late stage, but if the patient can afford the new steeply-priced patented drugs that promise higher efficacy, they sometimes recover with low chances of relapses. Not always.
And there’s been a precedent to this problem. More than 100 oncologists in the US wrote a letter in 2015 stating that rising cancer drug prices were not effective for the price they charged, leaving some of their patients bankrupt.
The Indian market is divided between generics and patented drugs, said a senior executive with the Indian office of Eli Lilly. This captures approximately 60% and 40% of the value of the market, respectively. When it comes to the volumes—three-fourth patients use generics and the remaining are able to buy patented drugs.
Generics are focused on comparatively affordable chemotherapy drugs and the MNCs focus on newer therapies like immunotherapy, targeted therapy, and biosimilars.
But there might still be some hope for those who look towards newer therapies. Without burning a hole in their pockets.
The chosen few
The answer is MNCs running support programs.
The patients are handpicked and either get drugs for free or at heavy discounts, said the head of the oncology department of an MNC that sells oncology drugs in India. For instance, Roche, under ‘The Blue Tree Programme’ in India, gives discounts or bundles one dose of the drug with a few free doses only for cancer patients who cannot afford these drugs.
Its reach, however, was limited to about 4000 patients in 2017. Such programs allow MNCs to sell drugs at international prices in India, he added.
None of the MNCs look at India as a low-income country despite the large economically disadvantaged population. There is a huge gap between patients who don’t receive treatment and those who do. Both hospitals and oncologists are limited in numbers. Therefore, only about 5% of the population demand oncology drugs, and they’re usually rich, said the MNC executive quoted above.
Further, when MNCs consider pricing for developed markets, they analyze the pharmacoeconomics. For instance, the National Health Service in the UK either procures or approves the reimbursement of oncology drugs and hence wants to know the benefit of the new drug over the previous class of drugs.
MNCs have to prove how the new drug will save the number of hours, the number of beds for the number of patients to justify its price.
What are the factors?
Thus, he said, pricing is initially driven by two factors: 1) international price and 2) the lowest price a country like India, which has little insurance and government procurement, can fetch.
Since India contributes a small percentage in any MNC’s global revenue for oncology, MNCs do not want to expose their new drug to a lower price in India. It becomes a reference point for procurement or price control agencies in other Asian countries.
Low pricing in India could spoil prices in other countries, which is why MNCs launch patient assistance programs that do not have a price. There is no incentive to lower prices and the only indirect way to increase access is these programs, he added.