Alastair Whitington summarises highlights from the Commissioning Chemotherapy Services Conference
The Commissioning Chemotherapy Services Conference was held on 6 December, 2018 at the Pullman London St Pancras Hotel.1
Dr Jeanette Dickson, Vice-President, Clinical Oncology, Royal College of Radiologists, Consultant Clinical Oncologist, Mount Vernon Cancer Centre, and Chair of the United Kingdom Chemotherapy Chemotherapy Board, welcomed delegates to the meeting and outlined a wide-ranging programme covering an update on the cancer strategy and national initiatives through to the day-to-day challenges of accessing treatments for patients with cancer, adopting new technologies, and delivering a high-quality support system for patients with cancer.
UPDATE ON NATIONAL CANCER STRATEGY
David Fitzgerald, Director, NHS Cancer Programme, provided an overview of the NHS Cancer Programme and its long-term plan. While cancer waiting times continue to present a challenge, there was a small improvement (0.7%) in 1-year survival in 2015 compared with 2014. Future goals include increasing the proportion of patients diagnosed with cancer at an early stage from 50% to 75%, with the aim that 55,000 more people with cancer will achieve 5-year survival each year through to 2028. This would be achieved by reducing the bowel cancer screening age from 60 to 50 years, improvements in screening techniques and take up, developing rapid diagnostic centres for cancer across the UK, investing in the latest scanners, and providing targeted lung health checks.
A £130 million investment in radiotherapy, the introduction of chimeric antigen receptor T-cell (CAR-T) therapy, and a significant investment to grow the cancer workforce will help meet the estimated 30% increase in cancer incidence, and improve treatment.
COMMISSIONING CANCER DRUGS
David Thomson, Chemotherapy Pharmacist, NHS England Chemotherapy Clinical Reference Group and National Cancer Drugs Fund, highlighted that affordability of novel treatments is an increasingly significant challenge for the NHS. The NHS steadily increased its budget for treatments between 2010 and 2015, with cancer representing the largest contribution to the increase (25%). The Department of Health and NHS England, in collaboration with NICE, should therefore ensure that affordability is considered when making decisions that have an impact on specialised services.
The NHS steadily increased its budget for treatments between 2010 and 2015, with cancer representing the largest contribution to the increase (25%).
The opportunity for NICE to refer cancer treatments to be evaluated through the Cancer Drugs Fund (CDF) means that cancer treatments have an advantage over other diseases where the decision is simply approval or non-approval. With this privilege comes the responsibility for those working in cancer to be rigorous in appraising, commissioning, and prescribing cancer medicines to deliver the highest standards of clinical and cost-effective evidence-based therapy.
Mr Thomson noted that the Systemic Anti-Cancer Therapy (SACT) dataset may provide the basis for developing algorithms to commission new treatments based on patient outcome data. He believes that algorithm development and their endorsement and use in commissioning by NHS England will protect cancer treatment options for patients, at a time when there is ever greater financial pressure on the NHS.
NICE – UPDATE ON NEW CANCER DRUGS PROCESS
Dr Linda Landells, Associate Director, Technology Appraisals, CDF, stated that the aim of the CDF is to provide faster access to new treatments, drive stronger value for money for taxpayers, and offer a fast-track route to the most promising treatments on the condition that companies price them responsibly.
Prior to the implementation of the CDF, Dr Landells noted that there would be no funding available for new treatments until 90 days after the final guidance from NICE had been issued, which may be up to 8 months after the initial appraisal meeting. With the CDF, all new treatments that have a positive outcome from the first appraisal meeting have the option of being funded by the CDF, which can mitigate the 8-month delay associated with waiting for the final guidance from NICE. Treatments are permitted to use this fast-track, managed access route if they have demonstrated promising efficacy, but with a degree of clinical uncertainty, and the company has reached a commercial agreement with NICE. To the end of October 2018, 26,500 patients had been registered to receive 70 treatments across 127 cancer indications within the CDF, more than 8000 patients had accessed new treatments owing to managed access agreements, and nearly 7000 patients had benefited from earlier access to novel treatments.
Dr Landells concluded by noting that the CDF offers a partnership approach to health technology assessments and commissioning, provides quicker access to cancer treatments via interim funding after a positive NICE recommendation, and enables patient access to treatments that are associated with significant uncertainty.
SACT – LEARNING FROM REAL WORLD DATA
Dr Rebecca Smittenaar, Analytical Lead, Public Health England (PHE), provided an interesting overview of the insights that can be gained from analysis of the SACT dataset. PHE is responsible for cancer registration, which is underpinned by a variety of datasets including the Cancer Outcomes and Services dataset. In addition, PHE collects several bespoke datasets, including those that are used for the SACT database. Dr Smittenaar noted that SACT data are important for identifying patterns of service provision, ensuring patient safety, supporting the evaluation of clinical effectiveness, and identifying and addressing variation.
Dr Smittenaar advised that the SACT database supported the PHE and NHS England partnership, which aims to provide data and analysis to support the CDF, enabling NICE to consider real-world data during final appraisals, in addition to results from ongoing randomised controlled studies. For example, SACT data has been used for the reappraisals of pembrolizumab for patients with non-small cell lung cancer (NSCLC) and brentuximab vedotin for patients with Hodgkin’s lymphoma. The types of report that PHE develops were outlined by Dr Smittenaar, including routine reports on treatment activity at trusts presented in a way that is easily understandable and can be compared over time.
Dr Smittenaar presented data concerning whether age is a barrier to receiving chemotherapy. By 2030, UK estimates suggest that 76% of cancers in men and just under 70% of cancers in women will occur over the age of 65 years. The management of these older patients with cancer presents a significant challenge to the NHS owing to variations in physiology, the presence of co-morbidities, polypharmacy, and differences in social background compared with the population aged under 65 years. Dr Smittenaar highlighted that older patients are historically under-represented in clinical trials, and that some studies have shown that fit elderly patients derive similar relative benefits from SACT to younger patients.2
To determine if age independently predicts access to SACT and if there is variable prescribing of SACT between NHS trusts, Dr Smittenaar and her team investigated three cohorts of patients with breast cancer (stage 2 or 3), colon cancer (stage 3), or NSCLC (stage 3B, 4 or palliative SACT). In all three of these cohorts, patients aged 65 years or older had a reduced chance of receiving SACT, despite deriving the same net benefit compared with younger patients. In addition, there did not appear to be much variation between trusts in their access to SACT, but trusts tended to be more variable regarding whether they prescribe SACT for older patients.
… patients aged 65 years or older had a reduced chance of receiving SACT, despite deriving the same net benefit compared with younger patients.
SERVICE IMPACT OF WIDE-SCALE USE OF IMMUNOTHERAPIES
Dr Ruth Board, Consultant Medical Oncologist, Lancashire Teaching Hospital NHS Trust, opened her presentation by stating that immunotherapy had recently become an interesting treatment option for a number of patients with cancer. Immunotherapies have been approved for a number of different tumour types, largely owing to immunotherapy demonstrating improved response rates and overall survival rates with less toxicity compared with chemotherapy, and the possibility of long-term survival in some patients e.g. ipilimumab in patients with melanoma.3
However, immunotherapies are associated with some challenges. For example, patients are receiving treatment with immunotherapies for a longer period of time than patients receiving chemotherapy because they can be administered for up to 2 years. This means that patients are living longer, with the consequence for the NHS of increased demand for resources. Immunotherapy is also generally associated with less toxicity; however, the safety profile is very different to that of chemotherapy. In addition, although there are published data from randomised controlled studies that suggest treatment with immunotherapy may confer long-term survival for some patients, not enough time has passed to truly investigate long-term survival and toxicities. To address the challenge of increased demand on NHS resources as a result of immunotherapy, Dr Board emphasised the need for alternative ways of working to increase efficiency and productivity through the introduction of telephone triage, nurse/pharmacist-led clinics, delivery of immunotherapy at a patient’s home or a designated off-hospital site, and investment in the education of patients and healthcare professionals.
THE SACT competency passport for nurses
Dr Catherine Oakley, Chemotherapy Nurse Consultant, Guy’s and St Thomas’ NHS Foundation Trust, presented on the patient-focused SACT competency passport, launched in September 2017, which aims to standardise the essential skills and knowledge for SACT nurses across the country. This will enable them to move freely between practice settings, provide equitable care for patients, and ensure a high level of quality assurance.
Professor John Weinman, Professor of Psychology as Applied to Medicines, King’s College Hospital, cited evidence from the World Health Organization (WHO) that approximately 50% of medicines prescribed for long-term illnesses were not taken as directed, with even higher levels of non-adherence to behavioural advice (e.g. improving diet, exercising etc.).4 The WHO posited that if treatment is evidence-based then this represents a loss for patients and the healthcare system.
Professor Weinman highlighted the need to increase awareness of the extent and effect of non-adherence, to use patient-friendly/collaborative questioning when asking patients about adherence, and to be able to identify specific reasons for non-adherence for each patient and tailor appropriate interventions to these reasons.
new medicines update
Dr Paul Catchpole, Director of Value and Access, Association of the British Pharmaceutical Industry (ABPI), highlighted some of the many challenges and opportunities that the NHS faces in the near future. His presentation was covered in the February 2019 issue of Specialised Commissioning.
- Succinct Medical Communications. Meeting report: commissioning chemotherapy services conference. December 2018. Available at: az659834.vo.msecnd.net/eventsairwesteuprod/production-succinct-public/d76fc1e2d92f44aa94036a2482810f8a
- Hutchins LF, Unger JM, Crowley JJ et al. Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med. 1999; 341(27): 2061-7.
- Schadendorf D et al. CTLA-4 immune checkpoint pathway inhibition using ipilimumab: pooled OS data from melanoma patients. European Cancer Congress 2013. Abstract 124LBA.
- World Health Organization. Adherence to long-term therapies: Evidence for action. www.who.int/chp/knowledge/publications/ adherence_report/en/ (Accessed April 2019)