1. Bengt Jönsson, Professor emeritus Stockholm School of Economics
Comparator Report on Patient Access to Cancer Medicines in Europe – Netherlands
Bengt Jönsson, Professor emeritus
Stockholm School of Economics

2. IHE comparator report 2016:4
Published in June 2016
Includes EU28, Switzerland, Norway and Iceland
Retrospective analysis over two decades

3. Burden OF CANCER

4. Cancer incidence is increasing in NL, just as in Europe as a whole
Cancer incidence rates among women were the second highest in Europe in 2012.
Cancer incidence across Europe rose 31% from ; demographic changes contribute to this growth, with improved diagnostics and screening playing a role.
Source: Adapted from Comparator report, data from Steliarova-Foucher et al (2012), Ferlay et al (2013)
Cancer incidence cases per 100,000 inhabitants (crude rates, both sexes)
Notes: Hatched bars indicate that national estimates are based on regional data or based on neighboring countries.

5. At the same time cancer patients live longer
Netherlands 5-yr relative survival rate from diagnosis was 56% for cancers diagnosed between 2000 and 2007 which is slightly higher than the European average of 54 %.
5-year age-adjusted relative survival rates for all cancers in patients aged ≥15 years, 1990–2007
Notes: Hatched bars indicate that national estimates are based on regional data.
Source: EUROCARE-3 to EUROCARE-5

6. Number of cancer mortality cases have been increasing in NL (crude rates, both sexes)
Source:
Number of cancer mortality cases have been increasing in NL
This may be explained by the large increase of cancer incidences and demographic factors

7. Once demographic factors are accounted for, cancer mortality case decreased in NL over the past decades
Source:
Cancer mortality cases per 100,000 inhabitants (age-standardized rates) both sexes, Netherlands

8. Cancer has overtaken CVD in NL during the period 2000-2012

9. SPENDING ON CANCER CARE

10. Changes in the composition of total cancer costs
While the share of health care expenditures spent on cancer has been stable, there have been important changes in the composition of total costs of cancer as can be seen by this graph...
A major contributing factor is the shift from in-patient to ambulatory and home care. This trend has been supported by the development of less toxic cancer medicines, oral agents and supportive drugs.
Components of the total cost of cancer in the EU (in billion €; 2014 prices), 1995–2014. Notes: Cancer is defined as ICD-10C00-D48 for health expenditure and ICD-10 C00-97, B21 for production loss due to premature mortality. EU = European Union; h-exp = health expenditure on cancer; m-loss = production loss due to premature mortality from cancer during working age.
References: Jönsson B et al. Eur J Cancer 2016; 66: 162–170.

11. The Netherlands (M€; unadjusted 2014 prices)
Notes: “direct” = direct health cost of cancer; “m-loss” = productivity loss due to premature mortality from cancer prices.
Cancer is defined as ICD-10 C00-D48 for direct health costs, and C00-C97,B21 for productivity loss
Notes: “direct” = direct health cost of cancer; “m-loss” = productivity loss due to premature mortality from cancer prices. Cost of cancer drugs not reported separately in 1995 and 2000 – the cost of drugs is included in direct costs for these years.

12. Hospital costs for cancer have been reduced over time: Will this trend continue?
NL hospital budget for secondary care (billion €)
The budget is increasing until 2017 and then slowly decreasing during the following years
Hospitals have made an agreement to cap the hospital budget in 2016 by a growth percentage of 1%
Note: Budget determined by the state for secondary care.
Source: Rijksbegroting 2016 (2015)
Note: Budget determined by the state for secondary care
Source: Rijksbegroting 2016 (2015)

13. The proportion of spending on cancer doesn’t reflect the burden of disease
5,7% of THE while almost one in four people die of cancer.

14. Use of cancer medicines

15. NL performs well but could still improve its outcomes
Netherlands survival rates are consistently higher than UK´s survival rates, conversely Netherlands survival rates are lower than Germany and Sweden's in almost all cancers.
Netherlands perform relatively poor in Kidney cancer were Germany had a 17 percentage points higher survival rate than Netherlands, but 8 percentage points higher survival than UK in ovarian cancer.
Source: De Angelis et al. Cancer survival in Europe 1999–2007 by country and age: results of EUROCARE-5-a population-based study. Lancet Oncology 2014: 15: 23-34
5-year age-standardised relative survival for adult patients with cancer, diagnosed 2000–07
* Belgium had only part of the population covered by cancer registration
5-year age-standardised relative survival for adult patients with cancer, diagnosed 2000–07

16. Launch delay: nine-fold difference in Europe
Netherlands has the 2nd shortest launch delays for in-patient oncology drugs
Short launch delays is important for patients access to new oncology drugs
Issue: Innovative pricing & reimbursement models is needed to address inequalities and ensure access based on medical need.
Launch delay for in-patent oncology drugs in Netherlands is 2nd shortest in Europe.
Difference in delays may stem from patent holders incentive to delay launch in low income countries until agreed terms in high income countries due to external reference pricing
Delays may also derive from administration in terms of, price-setting, reimbursement, regulatory requirements and drug approvals, these administrative problems is more evident of new EU members
The recent introduced measure to place some medicines which are associated with financial risk into “the lock”, i.e. temporary placing them outside the reimbursement package may have a negative impact on launch speed the access to new medicines.
For intramural pharmaceuticals I will regulate the open inflow for products that incur financial risk. In 2016, I will further shape the financial arrangements instrument and the legal anchoring of the possibility of putting a drug covered by the medical care performance formulated in the Healthcare Insurance Act temporarily outside of the package.
In 2016, some medicines will be put into a lock on an occasional basis in order to reach a financial arrangement and any appropriate use agreements.
ZiNL/Quality Institute organises appropriate and optimal introduction of new expensive drugs with stakeholders, at least for medicines that are in a lock.
Source: Europe Economics, External Reference Pricing, July 2013.

17. Uptake of Trastuzumab (Breast)

18. Fastest launch times <> widespread use or uptake – the case of drugs in HER2+ breast cancer
Use of HER2+ breast cancer drugs in 2014
DDD usage of HER2+ breast cancer drugs is lowest among wealthier countries.
Note: Eribulin omitted as it lacks a DDD.

19. Fastest launch times <> widespread use or uptake – the case of drugs in HER2+ breast cancer

20. Uptake of Erlotinib (Lung)

21. Fastest launch times <> widespread use or uptake – the case of drugs in lung cancer
Use of lung cancer drugs in 2014
DDD usage of lung cancer drugs is in the middle of wealthier countries.

22. Uptake of Lenalidomide (Myeloma)

23. Fastest launch times <> widespread use or uptake – the case of drugs in myeloma cancer
Use of myeloma drugs in 2014
DDD usage myeloma drugs is in the middle of wealthier countries.

24. Conclusions
Survival rates have increased all over Europe (up 56% in Netherlands between 2000 and 2007).
Health care expenditures on cancer are low in relation to the burden of the disease which continue to increase
Health care expenditures on cancer has been stable as a share of total health care expenditures
Innovation in cancer diagnosis and treatment challenges existing patterns of care
Despite having among the fastest launch times in Europe, uptake of cancer medicines varies significantly in the Netherlands

25. Thank you! bengt.jonsson@hhs.se

26. Uptake of Imatinib (CML)

27. Uptake of Bevacizumab (Colorectal)