Saturday August 15, 2020

Wealth should not determine cancer outcomes – but often it does

Patients in the public system are often unable to access life-changing treatments, such as immunotherapy for stage three melanoma, which are available to private patients

23rd July, 2020

Two patients arrive to a clinic. They are the same age, gender and height. They live within a five-minute drive of each another and they support the same sports team. Unfortunately, they were both recently diagnosed with stage three melanoma and underwent surgery.

However, their similarities end when it comes to health insurance cover. One has a comprehensive private insurance plan while the other relies on the public health system. But no big deal, right? This is cancer care we’re talking about.

Private insurance might give you access to a private room and slightly more palatable hospital meals, but cancer outcomes should remain the same in the private and public health systems? Both of our patients should have the same chance of remaining cancer free?

Sadly, when it comes to stage III melanoma in Ireland, this is not the case.

For the past year, patients with VHI health insurance have been able to access immunotherapy to prevent recurrence of stage three melanoma after surgery. This evidence-based intervention is not automatically available to all those with other health insurance policies or those without a health insurance policy.

This is despite immunotherapy being available in a large number of other European countries, including Britain.

Immunotherapy has revolutionised melanoma treatment, a cancer which is notoriously difficult to treat at later stages. It is given in this setting to prevent the cancer from returning and to eliminate any microscopic cancerous cells that may remain. In ongoing clinical trials, these medications are increasing the proportion of patients who remain cancer-free.

I am fortunate enough to be among the cohort of patients with stage three melanoma receiving immunotherapy post-surgery. At this point, it is worth explaining what the alternative pathway is.

Active surveillance or a “watch and wait” strategy is currently the standard of care in the public system, outside clinical trials. This means close monitoring after surgery and regular scans, but generally no medication.

The word “wait” has always been disconcerting to me, as if recurrence of this cancer is an inevitability rather than a possibility. Indeed, for more than 50 per cent of patients following this regime, their cancer will recur, often proving fatal.

I am also fortunate enough to be a medical student, entering my final year of study. Being diagnosed with cancer during medical school, while bewildering and shocking, also offers insight into what is like sitting on both sides of the clinic table.

In medical school, I have been taught the importance of evaluating the cost of new medications, which are often extremely expensive. Our health service only has limited resources and using these resources in one area may be detrimental to another. Oncology cannot exist in an environment immune to cost and resource scarcity, and rationing is important in any fair healthcare system.

Immunotherapy in this setting has been evaluated for cost effectiveness. This resulted in a recommendation for “reimbursement if cost effectiveness can be improved relative to existing treatments”. It failed to fall beneath the threshold set in order to be automatically reimbursed, but not by a large amount.

The data used to calculate cost effectiveness is still emerging, and this treatment may ultimately end up falling beneath this threshold. Additionally, there is a large unmet clinical need in melanoma treatment.

The “existing treatments” refer to the aforementioned “watch and wait” strategy. In the meantime, patients in the public system are unable to access life-changing treatments.

Cost-effectiveness aside, the disparity in access to these medications is fundamentally unfair. Wealth should not determine cancer outcomes. One of the key goals set out by our government in 2017 in the ten-year National Cancer Strategy is that patients should “have equitable access to the most advanced treatments available”. This is not the case in Ireland in 2020.

As long as our two patients are treated differently, we cannot claim equitable access. Receiving a cancer diagnosis is a terrible blow, this should not be compounded by harmful healthcare inequality.

Conor Stapleton is a medical student at Trinity College Dublin

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