3rd Asia Pacific Prostate Cancer Conference (APPCC), Shanghai, China
Cost constraints affect treatment decision-making in China and Singapore
Prof Kurt Miller - Benjamin Franklin Medical Centre, Berlin, Germany (KM)
Dr Li-qun Zhou - Peking University First Hospital, Bejing, China (LZ)
Dr Ravindran Kanesvaran - National Cancer Centre Singapore, Singapore (RK)
KM: Welcome to ecancer. We’re here in Shanghai at the third meeting, perspectives on castration-resistant prostate cancer. My name is Kurt Miller. I work in the Charité in Berlin, Germany, and I’m happy to have a discussion here with my two colleagues from China and Singapore. I would like them to introduce their selves.
LZ: Dr Li-qun Zhou from Peking University, First Hospital, Department of Urology, Institute of Urology, Peking University of Beijing, China.
RK: I’m Ravindran Kanesvaran, Medical Oncologist from the Department of Medical Oncology, National Cancer Centre, Singapore.
KM: So we’re probably working in different parts of the world, we’re in completely different situations, what we currently do with CRPC patients. Professor Li-qun, explain to me, what is the current situation in China? What drugs are actually available in the present and how do you treat?
LZ: You know, China is a little bit, I mean, simple for me to answer the question because now we mainly use, I mean, chemotherapy, docetaxel, cabazitaxel, there’s only available drugs. But for abiraterone, enzalutamide, radium-223, they’re all on clinical trials not launched in mainland China, so we have to wait for those drugs.
KM: So currently your options for treating CRPC is still chemotherapy?
LZ: Chemotherapy.
KM: And is it…? What is your perception? Is it that actually all the patients that are candidates do get chemotherapy or does it depend on the experience of your…?
LZ: Yes, of course it depends on the patient. I mean, physical condition for ECOG score. Of course we have patients not available to receive chemotherapy, but we do have some patients on clinical trials for abiraterone and radium-223, but it’s still on clinical trial.
KM: What’s the situation in Singapore?
RK: So I’m quite fortunate that we, in Singapore we have nearly most of the approved drugs in the US and in Europe, like abiraterone. In the chemotherapy side we have docetaxel, cabazitaxel. We also have radium-223 available. We have the bisphosphonates, the monoclonal antibody, the denusomab for, you know, treating bone mets. So apart from sipuleucel-T and enzalutamide I think much of the other drugs are available for treatment of castration-resistant prostate cancer patients.
KM: So what are the…? Okay, that’s what’s available, so abiraterone is also available for first-line treatment?
RK: Yes.
KM: So what is…? What’s then daily practice in Singapore? Is it that it’s still some patients get chemo, some patients get abiraterone first-line, or what’s the daily…?
RK: So I think like many countries patient preference does come into play and there’s some sense of reluctance by many patients to want chemotherapy, even if they are severely symptomatic. And there’s data that shows that even in symptomatic patients a drug like abiraterone may work, so many factors come into consideration. We use it in either setting. I think from the patient’s perspective the issues have to do with toxicities, efficacy and cost. Because Singapore does not have national health insurance, so if the patient does not have private insurance a lot of the cost will be borne by the patient themselves and that’s a substantial number of patients.
KM: So it’s not like in Europe and Germany, you know, the costs of abiraterone are basically covered by the health insurance system. That’s not the situation in Singapore?
RK: Not the situation in Singapore.
KM: Is chemotherapy covered in mainland China by…?
LZ: No, most of the drugs are paid by patients themselves. Because for docetaxel, yes, we have for group in my department, department of urology, Peking First Hospital, they specialise in chemotherapy and… but for docetaxel it’s self-paid by patients, not paid by the health insurance system.
KM: So costs play a role in decision-making?
LZ: Cost?
KM: Costs. I mean, how costly the drug is, how expensive the drug is, does that influence actually at the end of the day your decision-making?
LZ: It’s expensive, but to compare with other drugs we’re launching, I mean, in Singapore, in Europe, in the United States would be much cheaper to compare. I think maybe abiraterone, sipuleucel-T.
RK: Cost is an issue in Singapore, yes.
KM: So, I mean, if the patient says, well, abiraterone is just too expensive for me, that happens?
RK: All the time.
KM: All the time?
RK: That presents a challenge. I come from a centre where we treat the public. It’s a public hospital so there are subsidised patients, but these drugs are not subsidised. So they get subsidies for, you know, blood taking and hospital admissions and certain types of drugs, but none of these drugs are subsidised. So as such cost plays such a very, very big role in treatment choice whereby, you know, what we choose will depend on how much they have to pay.
KM: So it’s not only a medical decision-making, it’s just a financial decision-making, and financial maybe at the end number one on the list and then medical and then…
RK: Because the financial toxicity may be…
KM: Yes, it’s, yes, I mean…
RK: It’s pretty high so, yes.
KM: Yes, we had made the same impression in Germany, you know. In the first year when the costs are higher and then it’s, the price is negotiated, and then in the first year urologists were more reluctant to give abiraterone. They needed to get used to it, but now we’re in a situation where we’ve got 70 to 80% patients actually get abiraterone first time. So what? Let’s just speculate and, I mean, this is interesting and you can say in a way it’s difficult because it should be medical decision-making what’s number one on the list, but actually it’s not. So when abiraterone is coming, let’s say in six to nine months in China, so then again will it be only for a minority of the patients because it’s so expensive?
LZ: In my opinion, I think that because we have a lot of running clinic trials supporting both pre-chemo or post-chemo, so at least I would recommend those drugs to my patients. But I think that the cost we have to pay much attention because you… it can’t be covered by the insurance health system.
KM: By the public health system?
LZ: Public health system. Just like so-called targeted drugs for renal cell carcinoma still very expensive. So maybe it can be done, but also like companies maybe.
KM: Yes, I mean, that’s what you say. If it’s a problem with getting the drug reimbursed and the patient has to pay the drug out of his pocket sort of, that shrinks the number of patients to a small percentage actually, I mean, because the drugs are really expensive. So what’s…? I mean, for Singapore then, you know, what’s on the horizon is enzalutamide. Will that…? I mean, we have the same. Will that change practice?
RK: Again, you know, it’s another drug in the arsenal of drugs that we have so it would be great to have it, but the determining factor as to how accessible it will be to castration prostate cancer patients would be the price factor. It will play a role. We know it’s efficacious, we know its toxicities, but in Singapore the challenge will be trying to deal with the pricing of the drug.
KM: I mean, just… all right. So currently do you give it following docetaxel or is it just not available at all?
RK: It’s not.
KM: It isn’t, all right. Well, we will… we have the discussion. Of course it’s available post docetaxel, but people would like to give it pre docetaxel and it’s… so you… some give it off-label, but it will take another six months until it’s available in the pre-chemo setting and then the discussion will come up, what do you give first? Do you give first abiraterone or enzalutamide, and it’s… of course we have few data on what’s… so one question from me is again radium-223; what is the role? You say it’s approved. It’s not automatically reimbursed. It’s also an expensive drug. How do you use that currently in your country?
RK: So we just had some experience with the early access programme and the health sciences authority just approved it, like just weeks ago, so no one has really been put on it outside of the EAP patient programme. So based on patient programme experience we had to follow certain criteria, so outside of that I… no Singaporean has got onto it yet, but it will be a matter of time since it’s been approved. If a patient can afford it, I would think that it would play a role, especially in, you know, patients who may have symptomatic bone metastasis and it has a really good benefit for them. So in discussion with patients it may be used even pre docetaxel.
KM: In the pre-chemo setting?
RK: Pre-chemo setting.
KM: Is radium-223 any issue in China? Is that on the horizon sort of that it will be…?
LZ: Yes, I think in the clinical trials maybe this year may be launching in mainland China. I’m not sure. We have for several… I had two back in, several times conference, I mean, just specialising in radium-223 phase one, phase two, and now they are phase three have published [unclear]. They had a very good result. I think maybe this year may be launching in mainland China.
KM: So if your patients are currently, your China, Chinese patients are currently mainly with chemotherapy, is that then what we discussed before by urologists, medical oncologists, both? Is there…? Is that both groups are treating patients?
LZ: Yes.
KM: How are these patients, you know, how are these patients managed? Are they going to the urologist every three months, every…? Is that…? Are they controlled by PSA? How are they…?
LZ: Yes, this will be the long talk. I mean, generally speaking most of the late stage so-called CRPC in my department, but we recommend them to the medical oncologist. But I don't know why, because maybe not a great number of their patients. So now in my department I just let… I have a group. Urologists, they also do surgery, but they specialise in chemotherapy for CRPC, yes, because such kind of chemotherapy don’t take too much time, just two or three days. You give one cycle and return.
KM: Is that out-patient treatment or are these patients in the department, or is it just…?
LZ: In department for just several… just two or three days, yes.
KM: Is it out-patient treatment in Singapore?
RK: Yes, chemotherapy, absolutely.
KM: So the patient just comes for the chemotherapy?
RK: Comes for chemo and goes home.
KM: That would be the same for us. And just as in your part of the world as medical oncologists…?
RK: Medical oncologists.
KM: …are doing, urologists are just operating so they have not developed the branch yet. They are specialising…
RK: I think in the past, before there was medical oncology it used to be urologists, but now, at least in 2004 when the drug got approved, medical oncology was well-developed by then in Singapore and all cases of castration-resistant prostate cancer that need chemotherapy come to medical oncologists. And as such the drugs that are used pre and post as well are more commonly used by medical oncologists like abiraterone and I presumably see this happening with enzalutamide. Radium-223, however, is given by the nuclear medicine, but…
KM: Yes, that’s a different story.
RK: Absolutely, because there are multiple specialties that will be involved in that. So I think we’re not really kind of…
KM: Are you doing these patients…? You know, in Europe there’s all this discussion about multidisciplinary boards and, you know, in the UK, for example, any patient with advanced prostate cancer is discussed in this type of multidisciplinary board where you have a guy from urology, medical oncology, radiotherapy, whatever you can think about is there. Is that the same?
RK: Absolutely. So we do that. Unfortunately, the patient volumes are very high so we need… we are generally selective. So some cases that are more complex, that need input from other specialties get discussed, some of the straightforward ones maybe not. So it’s still…
KM: So part of the patients are discussed, but not every patient?
RK: Not every patient.
KM: I think we’re in the same. What is the situation?
LZ: Yes, in my hospital we have such kind of cooperation. A training centre with a urologist, radiologist and also medical oncologist, and together we discuss. We have [unclear] diagnosis centre when some patients were put on discussion and decided what kind of treatment was suitable for such kind of patient, so so-called multidisciplinary treatment.
KM: So, gentlemen, thank you. Interesting discussion. I hope to see you next year again here in Shanghai. Thank you.
LZ: Thank you.
RK: Thank you.
