The Case For Cancer Care Reform In Malaysia

Experts moot a more efficient way of sourcing for cheaper cancer drugs, making minor legislative amendments to improve access to early treatment, and improving resource-sharing between public and private facilities.

KUALA LUMPUR, June 2 – Malaysians are becoming increasingly concerned about rising medical costs as the population ages and the prevalence of non-communicable diseases (NCDs) continues to increase.

Cancer, in particular — one of four groups of diseases that account for over 80 per cent of all premature NCD deaths globally, according to the World Health Organization (WHO) — is a costly disease to treat with prices for cancer drugs soaring.

While the government faces a mammoth task to revamp cancer care, medical experts are suggesting “simpler” ways to reduce the country’s disease burden for the NCD.

This includes being more efficient in sourcing for cheaper cancer drugs, making minor amendments to the law to improve access to early and proactive treatment, and improving sharing of resources between public and private facilities.

Make Cancer Drugs On WHO Essential List More Accessible

Medical experts suggest gaining immediate access to drugs that are close to patent expiration as a “more efficient” way of sourcing for cancer drugs.

Hospital Canselor Tuanku Muhriz (HCTM) consultant oncologist Prof Dr Fuad Ismail said cancer drugs that are cost-effective, several of which are included in the World Health Organization’s (WHO) list of essential medicines, should be made more accessible in Malaysia.

The WHO list includes chemotherapy drugs like tamoxifen, capecitabine, cyclophosphamide, docetaxel, doxorubicin, gemcitabine, paclitaxel, vinorelbine; targeted therapy drug trastuzumab; and hormonal therapy drug tamoxifen – all of which are listed in the Ministry of Health’s (MOH) Clinical Practical Guidelines for Management of Breast Cancer.

The WHO Model Lists of Essential Medicines are updated every two years by the Expert Committee on Selection and Use of Essential Medicines.

“The drugs which are cost-effective, we should really fight for. What we need to do, for me, is to increase our base treatment, not so much the innovative drugs – the base treatment is easy to move up.

“So, if somebody comes up and says they’ve got recurrent cancer or something, you should be able to get a second line treatment with a Taxol (paclitaxel) easily or gemcitabine without having to pay out of pocket. 

“These are cheap treatments because they are old drugs and they can still give you good quality and very reasonable treatment,” said Dr Fuad, who is also a Malaysian Oncologist Society committee member, at the “Oncology Summit 2022: Meeting the promise of cancer care in Malaysia” hybrid event last April 29, organised by the Galen Centre for Health and Social Policy and pharmaceutical company Takeda Malaysia.

“An elderly gentleman was thanking me profusely because I managed to get him paclitaxel from welfare and it is a 20-year-old drug and he just couldn’t afford even that,” said Dr Fuad.

Dr Fuad said many new drugs for cancer, despite being “amazing” in curing or improving the care for cancer, came with hefty list prices. 

“You can see that the cost of drugs have been increasing and that for the last, say, five years, most of the new drugs will come with a price tag of more than maybe US$100,000 (RM435,350). 

“So, getting a treatment that costs a million US dollars is still unusual, but we are getting treatment which actually costs that much,” Dr Fuad said.

Citing a list from compiled by companies and patient groups, Dr Fuad said eight cancer drugs approved in 2015 had a six-figure list price – namely, Tagrisso (US$153,000), Alecensa (US$150,000), and Portrazza (US$137,000) for lung cancer; Empliciti (US$140,000), Farydak (US$119,000), Ninlaro (US$113,000), and Darzalex (US$110,000) for multiple myeloma (blood cancer); and Ibrance (US$118,200) for metastatic breast cancer.

University Malaya Medical Centre senior consultant breast surgeon Prof Dr Nur Aishah Mohd Taib, who is also Together Against Cancer (TAC) vice chairman, said procuring and providing cancer drugs can be done more efficiently, without putting in more money.

Citing trastuzumab as an example, Dr Nur Aishah said Malaysia didn’t bring the targeted therapy drug “fast enough” into the country when the patent ended in 2014. The medicine was eventually brought into Malaysia in 2018.

“It took a while for the price to come down. And you must remember, patients need to take this for a year. So, they may be spending something like over RM100,000 just for curative treatments. We hope that by next year, the price will go down further. 

“You can see it’s almost halving the price every year, or two to three years,” Dr Aishah said.

The price of trastuzumab was RM6,000 in 2018, before it went down to RM3,000 in 2019 and RM1,500 in 2022. It is projected to cost even lower next year at RM700, according to Dr Aishah.

“We want it to be accessible for patients and whether or not we can do this – that’s why I think at TAC, we are trying to be a sort of watchdog by looking at the list of drugs that are now off patent and to see how we can work with other organisations.

“I think National Cancer Society Malaysia (NCSM) is also doing a lot of work on this – getting to see whether there are any other local manufacturers or even international manufacturers that can bring in these biosimilars and generic drugs legally through our National Pharmaceutical Regulatory Agency (NPRA) and all that,” Dr Aishah said.

Another way to make treatment more accessible to cancer patients is through clinical trials, said Prof Dr Gan Shiaw Sze @ Gan Gin Gin, professor in internal medicine and clinical haematology at the University of Malaya’s Faculty of Medicine.

“I think a lot of clinical trials, which as you know, in blood cancer, there have been leaps and bounds of advancement in novel drugs and immunotherapy by specific antibodies – those are not easily accessible. 

“But I think a lot of times, many pharmaceutical companies have actually forgotten or somehow skipped Malaysia as a centre for clinical trials.

“I think it is very important for the pharmaceutical company to realise we have a huge number of patients and our facilities are just as good. I think it is something that pharmaceutical companies should think about, not to skip us, but to provide us and our patients, the availability of participating in clinical trials.

“As we know, some of the clinical trials do translate into significant overall survival as well as clinical improvement and quality of life,” Dr Gan said.

Medical Fee Law Punishes Cancer Patients For Seeking Early Treatment

Dr Fuad and Dr Nur Aishah also called for a review of a regulation that imposes first class rates on cancer patients at MOH hospitals who are referred from private or university hospitals.

The Fees (Medical) Order 1982 has been the subject of debate among cancer patients, many of whom did their initial treatment at a private facility, as they cannot afford to wait months at government facilities for their diagnosis or first surgery. 

Dr Fuad said cancer patients should not be “punished” for proactively seeking diagnosis and early treatment for their condition.

“What happens is some patients, they have a little bit of money, then they take the initiative [to] go to the private [clinic] – get a quick CT scan, get a biopsy, get the diagnosis – and then you punish them. Because they come from private, you charge them a first-class rate… they don’t have the money. ‘I spend the little bit that I have [on early diagnosis]’.

“So, we need to get away from this because they (patients) took the initiative to look after their health and you punish them. So, it’s very unfair. So, the Fees [Order] is something that’s really, I feel, really bad,” Dr Fuad said.

According to the Fees (Medical) (Amendment) Order 2017, a one-bedded first class general ward is charged at RM120 per day, 40 times more expensive than RM3 for a third class ward. 

Rates differ for radiotherapy and oncology treatment at MOH hospitals too, with targeted therapy charged RM600 under the first class rate, 12 times more expensive than the third class fee of RM50. 

Outpatient targeted therapy treatments that are referred from a private practitioner are charged RM600, four times more than RM150 for referrals from a government hospital.

Dr Nur Aishah hopes policymakers will change the medical fee law as it affects cancer patients from bottom 40 per cent (B40) income groups.

“If you are seen by a private general practitioner (GP), for example, with a lump or symptom, and this person is [from the] B40 [group] and they need to access a government clinic, but with a reference letter from the private GP, they are then charged with first class fees. 

“These people are people who really need subsidies from the Ministry of Health (MOH) and they should not be [served] with first class fees,” Dr Nur Aishah said. “So, I really hope the policymakers are listening because if you need to change the Act, then change the Act.”

Cancer advocates had previously urged the Pakatan Harapan (PH) government to withdraw the medical fee law, saying that patients are still penalised with first class rates, including for hospitalisation and medicine, even if they want cheaper third class treatment.

Despite an earlier report of then-Health Minister Dzulkefly Ahmad wanting to review the medical fee legislation, the PH government eventually decided that the Act would remain.

Better Use Of Resources Between Public, Private Facilities

Another practical approach to making cancer care more efficient is to better utilise resources between the public and private sectors – as was seen in the public-private partnerships for Covid-19 under the now-disbanded Greater Klang Valley Special Task Force (GKVSTF).

“I think outsourcing [patients] to private hospitals, sometimes, in a busy hospital or certain hospitals may not have the facility, the government should think of outsourcing it to private hospitals,” Dr Gan said, adding that this could help cut waiting times at public facilities.

However, instead of simply channelling patients to private hospitals, Dr Gan said it would be more effective to “streamline” patients first by identifying those who need services more urgently.

“We should identify those who actually make a difference by having an earlier scan. Not everyone will benefit from an earlier scan, and not everyone will benefit from having repeated scans. I think by streamlining who needs it urgently, and if we are short, if certain places may not have the facilities, then outsourcing would be a good idea,” Dr Gan said.

The long waiting list at public hospitals in Malaysia often forces patients to seek faster, and usually costlier screening or treatment options at private hospitals. Dr Gan said UMMC is no exception, though the waiting is generally slightly faster at one or two weeks – depending on how “pushy” the doctor is to get their patients tested or treated.

“That’s the word: pushy. If you are pushy and you have a conscience, therefore, your patient gets the test done quickly. But the problem is not everyone will have the conscience or is pushy enough to get the test done quickly,” Dr Aishah said.

“Which is why I was saying about not just strengthening the health system, but by using managers, specific cancer managers within the hospitals, to navigate and to also ensure that the appointments are early. 

“Because if you talk nicely to the radiologist, and we are all very friendly with our radiologists, we can get our dates done quickly – within a week, within two weeks – but we have to take the extra effort of being there and that takes you away from consulting another patient.

“If you have cancer managers that are running to facilitate the patients throughout the journey, and I don’t think it’s a big investment, that is something that hopefully…we are trying to do that at UMMC but we are still a bit behind with the project. But that is something without much additional investment, you can actually get the impact,” Dr Aishah said.

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