Government boost for Pharmac - what’s in it for brain cancer patients?

Brain Tumour Support NZ chair, Chris Tse

The coalition government's announcement yesterday of a $604m funding boost for medicines over 4 years is welcome news for the cancer community and Kiwis battling a range of other diseases and conditions, but what does it mean for brain tumour patients?

Probably not a lot, unfortunately.

There were no brain cancer medicines in National's original promised list of 13 cancer medicines and there is nothing among the 147 applications currently awaiting funding on the Options for Investment (OFI) list. So unless Pharmac opt to go outside the OFI and choose to fund bevacizumab (Avastin) for brain cancer, brain tumour patients will not see one cent of the $604m announced.

Meanwhile, patients are self-funding their bevacizumab treatment, at a cost of thousands per year, not just for the drug but to have it administered in private clinics across the country (non-Pharmac funded medicines are not allowed to be administered in the public system). This is actually a nice little earner for the government as they clip the ticket with GST along the way.

Bevacizumab is not a new drug. It was approved by the US FDA in May 2009, over 15 years ago, and is already off-patent. Across the Tasman, Australian brain cancer patients have funded access to a bevacizumab biosimilar (a generic version of Avastin) as do many other brain cancer patients around the world.

Last year Pharmac's Cancer Treatments Advisory Committee (CTAC) recommended bevacizumab be funded for brain cancer with "low priority" and it is now waiting to be assessed under their Factors for Consideration framework.

Meanwhile, oncologists keep prescribing it and patients (those that can) keep paying for it. Why? Because it is providing meaningful benefit in terms of better quality of life, reduced steroid dose, and in many cases longer survival. Not a cure, but more quality time with loved ones.

So why is it that there are so few options for brain cancer patients in New Zealand and around the world? The last medicine approved in New Zealand for brain cancer was temozolomide, almost 20 years ago. Tumour treating fields (TTF) has extended average survival from 14 months to 20 months but is not widely available outside North America, Germany, Japan and a few other Asian countries.

Checkpoint inhibitors, transformative in many other cancers, have largely failed in brain cancer, although we are watching closely across the Tasman Prof Richard Scolyer's n=1 trial of neoadjuvant immunotherapy combined with a vaccine.

Further afield there are vaccine therapies, notably DCVax and SurVaxM, being evaluated. There are also clinical trials involving sonodynamic therapy, focused ultrasound, oncolytic viruses and CAR T-cells. The day will come when one or more of these promising treatments will graduate from clinical trials to become the new standard of care for brain cancer.

Which begs the next question, why are none of these clinical trials being run in New Zealand? Why can't New Zealand brain cancer patients gain access to new, innovative treatments as they are being developed rather than wait for them to be approved overseas and then slowly grind their way through the Pharmac funding process?

Brain cancer trials are hard. Standard treatment usually involves surgery, radiotherapy and chemotherapy, while follow-up and monitoring relies on advanced imaging such as MRI and PET-CT scans. New Zealand currently lacks the infrastructure to effectively run oncology trials and this will sadly remain the case until research becomes part of mainstream clinical care.

Pharmaceutical companies have the resources to run clinical trials here but they are disincentivised by the adversarial nature of Pharmac's drug reimbursement process. Why invest good money on clinical trial infrastructure and educating medical professionals when there is little chance that your drug will end up being funded?

Which leaves New Zealand brain cancer patients back at square one. Not only are there limited treatment options in terms of new medicines, but existing standard of care treatments such as radiotherapy are crumbling due to underinvestment. A recent report by the Royal Australia and New Zealand College of Radiologists painted a sorry picture of workforce shortages, ageing machinery and chronic underinvestment in the sector by successive governments.

So while we rejoice alongside the cancer community at the government's medicines funding announcement, we reflect on the sad reality that brain cancer will likely be left out again.