What do the new evolutions in GI cancer mean for my practices

Transcription

1 What do the new evolutions in GI cancer mean for my practices South (and Latin) America view Jorge Gallardo MD Medical Oncologist Santiago de Chile. «SLAGO working group» Chilean Foundation for Development Oncology 1

2 What do the new evolutions in GI cancer mean for my practices 1. Economic and social backgrounds 2. New drugs in metastatic disease 3. Adjuvant protocols 4. Radiotherapy 5. Diagnostic tests 6. Clinical Trials 7. New Guidelines 2

3 Economic and social backgrounds South America has 416, Latin America has 623 million people, (10% of world population) Gastric Cancer Colorectal cancer The cancer epidemiology in Latin America differs from that found in other regions:* higher incidence in gastric cancer Highest gallbladder cancers mortality mainly in Andean Pacific area Uruguay and Argentina have the highest incidence and mortality rate in colon, rectal and pancreatic cancers in the world**, East Atlantic area Galblader Cancer Esophageal Cancer Brazil and Uruguay the highest mortality rate in esophageal cancer** Ref: *Torre et al. 2015; ** Globocan 2012, Estimated incidence, mortality worldwide 3

4 2016 Portugal 30.2 Greece 26.7 Turkey 25.2 Poland 27.4 Latin America comprise low and mid per capita income countries in a great heterogeneous scenario 4

5 Investment in health according to OECD and WHO 5

6 With almost a fifth of expenditure per capita life expectancy is higher in Chile compared to USA Health expenditure per capita Life expectancy OECD 9.0% ($4 000) Life expectancy at birth (years) Life expectancy at age 60 (years) Both male female Both male female sexes sexes USA Chile Canada Uruguay Chart breaks it down by public and private expenditure In year 2012, Statistic 2014, last available static, accessed Feb/2017 Ref: Health expenditure per capita, 2014 (OECD stat); World health statitics, WHO

7 Health insurance systems in Chile and South America Public system 80% of overall population, including The poorest people Oldest (retired) Less educated Some handicaped and chronically ill patients Solidarity Equal access to health Saturated Old technology Each test done, every patient treated, means spending money Private system 15 % of population The richest part Active part (working actively) Best educated, high level Must be healthy when entering Insurance system Individualist Access to health according to «insurance primeum» Open to receiving patients New technology Each test done, every patient treated, means earning money Medicine Free Market Economic and social inequity is a generalized characteristic 7

8 What do the new evolutions in GI cancer mean for my practices 1.- A new expensive drug : i.e. Immunotherapy Public system It will take a lot of time to be included Some will never be included. When included, all population will have access to it To include a new expensive drug Increases expenditure Private system Almost all of them will be included They are already being used Oncologists are trying to get knowledge and training how to use it Price is less important/unimportant Access depends on quality of insurance It may increase Pats financial distress To include new expensive drugs Gives prestige Increases financial income to the private clinic

9 2.- Advances in neo or adjuvant therapies Adjuvant therapies utilize, commonly, old and/or cheaper drugs MAGIC and FLOT; FOLFOX and CAPOX, Gemcit adjuvant, etc. were rapidly included Neoadjuvant chemo-radiation for rectal cancer was rapidly introduced Chemo-radiation for esophageal cancer has been standard for a long time, nowadays with CROSS GOOD IMPACT!!! 9

10 3.- New technology for diagnosis: New MRI, CT, PET-CT Public system It takes time to get the machines Old technology Deficits, i.e. Only one PET-CT available for 80% of population Deficits in radiologists Pts get appointment with long delays To obtain report takes additional long time Saturated Each test done means spending money Private system All has been rapidly incorporated Less deficit, i.e. 6 PET-CT available for 20% of population No deficits on radiologists Access depends on quality of insurance Appointments for tests are obtained rapidly, reports are given faster Report and images are available through internet for Pats Open to receive patients Each test done means earning money Including new tests gives prestige to the private clinic 10

11 3.- New Technology in Radiotherapy Ref: Expanding Global Access to Rtx, Lancet Oncology Commission 11

12 3.- New Technology in Radiotherapy Public system Private system It takes time to have the new machines Deficits in specialists Pts get therapy with long delays Oversaturated Old technology All has been rapidly incorporated No deficits on radiotherapists Access depends on quality of insurance Appointments for treatment are obtained rapidly Open to receive patients Ref: Expanding Global Access to Rtx, Lancet Oncology Commission 12

13 4.- Advances in new molecular tests New molecular tests are related to new expensive drugs Frequently, tests are offered for free by the pharmaceutical companies Most tests are available in main cities of South- America Laboratories for DNA sequencing and other tests performed under fast delivering logistics are limited to few academic and private institutions. 13

14 5.- Participation in clinical trials The largest average annual growth in clinical trial participation occurred in lower-middle and low-income regions: Asian 30% Latin American countries 12%. Three Latin American countries ranked among the top 25 countries with high participation in pharmaceutical clinical trials: Argentine, Brazil and Mexico In terms of technology, research sites vary considerably Eccard et al. 2016; Thiers, Sinskey, and Berndt

15 5.- Participation in international clinical trials Many Latin American researchers are taking part in nowadays running trials Some researchers get to be one of top enrollers Until now, participation doesn t include the study design We are increasingly reluctant to publications/studies that don t include Latin American population Growth of clinical research infrastructure acts as a driver of overall health system development by introducing strong organizational and regulatory mechanisms and building local capacity and expertise in the medical field Lastly, increasing access to clinical trials in LMICs allow patients access to medicines that might be, otherwise, inaccessible 15

16 6.- IMPACT OF NEW GUIDELINES NCCN and ESMO guidelines are well known, but the updates are much less known In English Accessible only by internet Few accesses are available in crowded public hospitals Affordability of drugs/regimens are different Small impact, if any, in daily practice No impact in governmental decisions Reference for some insurance companies To have ESMO guidelines adapted to Latin America can impact the quality of cancer care!! 16

17 Five years Survival in Gastrointestinal Cancers in South America, Quinquenium (Reference two European countries) Oesophagus Stomach colon rectum liver pancreas Germany Spain , Argentine Brazil Chile Colombia Ecuador Uruguay y Survival 5 years survival colon cancer Quinqueniun Quinq Adapted from Concord Study The lancet March 2018

18 What do the new evolutions in GI cancer mean for my practices 1. Due to economic and social background there are big differences, high inequity 2. Less than 5-15% can have access to new expensive drugs in LA 3. New protocols using old drugs are rapidly included, specially in adjuvant setting 4. Radiotherapy, radiology, new diagnostic tests: available in big cities, mostly for a minority 5. Clinical Trials: Have accelerated increment, good impact 6. New Guidelines: Little impact in normal practices 7. In GI cancers the 5 years survival is much inferior to Europe and did not improve in last quinquenium New advances are associated with financial toxicities If we know the advances in oncology we can improve the results in prevention, quality of life, life expectancy, cure rate. 18

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