How changing the WHO’s list of essential medicines can improve cancer care across the globe
Since 1977, the World Health Organization (WHO) has updated and released an essential medicines list (EML). Through the EML, the WHO aims to promote affordable access to safe and effective medicines and provide guidance for healthcare systems across the world. The EML lists medicines spanning the entire healthcare spectrum, with one area of focus being cancer care and treatment. Most high-income countries, such as Canada, already have systems and organizations in place to help decide which cancer medicines and treatments should be provided for patients. However, many of the emerging cancer health systems in low- and middle-income countries (LMICs) do not yet have this process. As such, the EML is an important tool to help policymakers in LMICs prioritize which cancer medicines should be widely available to all patients. While the EML should reflect new and innovative cancer treatments, in order to be useful to the countries that need it most, this must be balanced with basic and affordable medicines, identified with the help of frontline oncologists from around the world.
Dr. Christopher Booth is a professor in the Department of Oncology and a member of Queen’s Cancer Research Institute. As a member of the WHO Cancer Medicines Working Group, Dr. Booth is committed to ensuring that the EML contains the medicines that will be most useful for patients globally, especially in low resource settings.
Together with the WHO, Dr. Booth and his colleagues have decided to take the EML to frontline cancer doctors across the globe.
In an ongoing study, Dr. Booth’s team collected data through an electronic survey, which was sent to thousands of doctors worldwide, asking frontline workers which medications they believed are the most essential. “The way that we framed the question is: imagine your government puts you in charge of cancer medicines and tells you that cost is not an issue, but you can only choose ten cancer medicines for your entire country,” says Dr. Booth. “What we want to know is which cancer medicines front-line clinicians would choose to derive the greatest public good, and then as a follow up, which of these medicines are actually available in their country. If the medicines listed are not available, then the survey follows up by asking why that is. Creating a list is one thing but it is crucial that we make sure that drugs are actually available on the ground.”
Dr. Booth hopes that this survey will help to identify medicines whose importance has been overlooked by experts, so that they can be added to future versions of the EML.
Another issue that Dr. Booth is concerned with is how a medicine’s price can impact whether it is available to patients. As the survey progresses, participants are asked to modify their previous list of essential medicines, but now factoring in cost. While some medicines offer benefits in terms of patient outcomes, they can be highly expensive. In order for the EML to be useful to low- and middle-income countries, it is important to identify medicines which offer substantial benefits to patients and are affordable.
“While many of the cancer medicines listed on the EML are highly effective low-cost older drugs, there are some oncology drugs on the list that are very expensive. The hope is that by listing these important medicines, countries will be able to better negotiate prices that make them affordable.,” says Dr. Booth. “Having said that, there is a risk to this approach. If the cancer list includes too many of these ‘very high cost’ medicines, there is a risk that the Ministry of Health in a country with limited resources may decide the entire cancer list is not practical and decide not to fund any of the EML drugs – even those that are relatively affordable. We have to balance perceptions carefully to ensure that we maximize patient access to important medicines while recognizing the complex realities of delivering care in these emerging health systems.”
This balancing act is one that, through his research, Dr. Booth is trying to encourage more of. Five years ago, he spent his sabbatical working at a cancer centre in South India which radically changed his career. While working in India, Dr. Booth realized the positive impact that implementing fairly basic and inexpensive interventions could have on public health, and since then he has devoted his career to doing just that.
“Living and working in India had a profound impact on the way that I see things and demonstrated to me how important it is to balance the cancer ‘Moonshot’ with the cancer ‘Groundshot’,” says Dr. Booth. “A ‘Moonshot’ has big aspirational goals that may change the cancer landscape over the next 1-2 decades. It is an expensive, high-risk investment in research. While Moonshot research and treatments are important, most medical systems overly prioritize them. Our group feels that we need to better balance ‘Moonshot’ with ’Groundshot’ initiatives.”
‘Groundshot’ initiatives are those that bring research and practice down to the ground and ensure that the medicines and treatments are already known to have large patient benefits are made widely available. “Radical improvements in cancer outcomes in India or sub-Saharan Africa are not going to come from expensive new medicines or fancy robotic surgery,” says Dr. Booth. “The largest public health benefit will come from investments in health systems. This will strengthen primary care to facilitate early diagnosis, and ensure that patients have access to high-quality surgery, fundamental chemotherapy/radiation, and palliative care.”
The WHO work fits into Dr. Booth’s broader research program which seeks to improve access and quality of cancer care for patients in Canada and globally. Ultimately, Dr. Booth hopes that his research contributes to changes in health policy and clinical practice that lead to improved outcomes for patients regardless of where they live.