Case Scenario: Immunotherapy Treatment for Cancer
Immunotherapy is cutting edge in the treatment of cancers. It works by helping the immune system destroy and slow the growth of cancer cells. There are a number of different types of immunotherapy. Monoclonal antibodies are developed in a laboratory and work like antibodies naturally produced by the body to fight off infection (Cancer Australia, 2019). Cancer is the term given to mutated cells which do not self-destruct when damaged. Unlike normal cells, cancer cells endlessly grow and divide, forming tumours. Metastasis occurs when cancer cells detach from tumours and spread throughout the body. Monoclonal antibodies slow the progression of cancer by blocking cell growth. Other treatments involve Cytokines (proteins produced by white blood cells during an infection) which are administered with other treatments such as chemotherapy and radiation therapy. Cytokines are most effective in cancers caused by infections (Cancer Australia, 2019). Monoclonal antibodies and cytokines are available to patients on the PBS. However, neither monoclonal antibodies or cytokines are sufficient to kill and eradicate all cancer cells. They are administered with a view to lengthening and improving quality of life for patients who have cancer, rather than as a cure. Cancer survival is still largely contingent upon the detection of cancer prior to metastasis (the spreading of cancer cells to other parts of the body).
Snapshot of Cancer in Australia
In Australia, one in three people will have contracted cancer by the time they are 85 years of age. According to the Australian Institute of Health and Welfare (AIHW), currently seven in ten people survive for at least 5 years post cancer diagnosis (AIHW,2019). Screening and education programs have helped to attain a 90%+ survival rate for some cancers due to early stage detection (breast, prostate, melanoma, and bowel cancer). However, five-year survival rates of cancer decrease with every increment in stage at diagnosis. Stage IV diagnosis of any cancer (post metastasis) correlates to an approximate survival rate of 10%.
There are 50,000 cancer related deaths per year in Australia (AIHW), 2019). Mortality from cancer is skewed by age, location and socio-economic status. People in the lowest socio-economic quintile are 37% more likely to die from all cancers, and 85% more likely to die from lung cancer, compared with people in the highest socio-economic quintile (AIHW, 2019). People living in very remote areas are 24% more likely to die from cancer compared with those in cities. The distribution of cancer mortality rates is skewed to people aged 65 years or older which represents 78% (38,713) of all cancer deaths. However, cancer impacts all age groups. 199 children and young adults (0-24 years), 2242 aged 0-49 years, and a further 8,743 people aged 50-64 years, are expected to die of cancer in 2019 (AIHW, 2019).
Super Antibody Cure for Cancer (Fictitious)
The Anpha pharmaceutical company based in Ireland (fictitious) has recently made a new breakthrough creating a super antibody (Braxane). Numerous clinical trials have established Braxane as a cancer cure. The treatment involves a series of injections administered every two weeks for a period of between 12 and 24 months. Post metastatic cancer requires the full two years of treatment, but cancers detected earlier can be cured within the first 12 months. The miracle of Braxane is that it can also avert new cancer growth by building up enough antibodies to prevent cancer cells from developing. Therefore, to ensure lifelong remission, patients treated with Braxane are required to undertake an annual booster shot of Braxane for the rest of their lives. Treatment and booster injections can be administered to patients in out-patient clinics. There are virtually no side effects to the treatment other than general malaise and fatigue as the body repairs itself, thus minimising the requirements for hospitalisation. News of Braxane has been publicised globally, and the treatment has been hailed the most significant medical break-through since the development of antibiotics. The drug has been patented as is standard in the EU for the next 20 years. The treatment has been marketed at a cost of $10,000 per injection in order to recoup the significant research and development costs borne by Anpha.
Pharmaceutical Benefits Scheme (PBS)
The PBS is a redistributive policy ensuring equity of access to prescription medications by subsidising the cost. All Medicare card holders in Australia pay a maximum $40.30 co-payment for medicines listed on the PBS or $6.50 for concession card holders regardless of price (Department of Health, 2019a). Medicines listed on the PBS are delivered to a network of community and hospital pharmacies across Australia though wholesalers. Wholesalers operate under a Community Service Obligation (CSO) and are subsidised by the Australian Government to supply drugs to pharmacies across Australia irrespective of how remote (Department of Health, 2019b). Wholesalers and pharmacists therefore form the supply chain needed to ensure that medicines are available in a timely manner and at an affordable cost to all Australians.
Anpha has applied for Braxane to be evaluated by the Pharmaceutical Benefits Advisory Committee (PBAC) for inclusion on the formulary listing of the PBS. The PBAC evaluate all new applications and recommend to the Federal Minster of Health which drugs should be PBS listed. The evaluation includes a cost effectiveness criteria and any listing expected to cost more than $20 million over four year estimates requires the approval of the cabinet (Department of Health, 2019c). The effectiveness of Braxane is not in doubt but due to its high cost it could not be recommended by the PBAC for PBS listing.
Economic and Political issues (Fictitious)
Australia has plunged into a deep recession due to ongoing tension and trade wars between the USA and China. This has resulted in a doubling of the unemployment rate now at 12.4 % and a significant increase in underemployment (from 8.5% in 2019 to 22.3%) as the economy has contracted. Having managed the economy out of the debt incurred by the previous labour government, the liberal national coalition has so far resisted calls for economic stimulus and greater public spending. However, the government has just announced a trade deal with the US set to provide a much needed boost to the economy. An election is looming and the coalition are campaigning on their economic management credentials. To maintain a healthy budget surplus, public hospitals have recently had 20% of their federal funding cut and therefore are unable to offer Braxane to patients unless they are able to fund it themselves.
The Cancer Council is leading a consortium of interest groups which are petitioning the government to amend the PBS cost effectiveness criteria, so that Braxane can be made available on the PBS. This group is supported by the Australian Medical Association (AMA), Doctors Reform Society (DRS), Australian Healthcare and Hospital Association (AHHA), the Close the Gap Campaign, the Public Health Association of Australia (PHAA), and a number of grass roots interest groups formed by the families of cancer patients. The consortium has been successful in creating awareness about the issue. Several documentaries and public debates have been aired on prime-time TV. The press and social media contain daily stories of families battling to fund the expensive new treatments. Some have even sold their homes only for their funds to be insufficient to pay for the annual booster shots and the cancer has returned. The recovery and cure of the CEO of a large Australian bank from stage 4 liver cancer and the cure of two members of a highly acclaimed rock band from end stage lung and pancreatic cancer, have been amongst the good news stories widely covered by the media. Both members of the rock band were known to have been heavy smokers and they have publicly declared their support for Braxane to be made available to others via the PBS.
Identify and describe:
- The public health issue depicted in the scenario
- The key policy actors involved
- The market or social justice ethics underpinning the position of key policy actors of this issue
Drawing on the sociological, political, and economic contextual factors shaping this public health issue explain:
- How likely it is that this issue will be placed on the public health agenda?
- The information and advice likely to be considered as part of the formulation of this public policy to address this issue?
- And outline the most likely policy solution to be adopted by government.
Anpha is likely to benefit from the listing of Braxane on the Pharmaceutical Benefits Scheme (PBS). Using concepts and theories discussed in the unit how do you think the pharmaceutical industry (Anpha competitors) are likely to react?
To answer this question:
- Describe the position Anpha competitors (pharmaceutical industry) are likely to take on the PBS amendment the Cancer Council Consortium is seeking.
- Identify and discuss the strategies and tactics that pharmaceutical competitors are likely to use to capture the PBS review debate.
- Explain which contextual factors are likely to strengthen or weaken the pharmaceutical industry’s capacity to shape the policy.
The PBS has existed since 1948. Identify and explain:
- Who is involved in the implementation of the PBS? Would this change if Braxane becomes available via the PBS?
- How is the PBS implemented drawing on policy implementation theory discussed in the unit?