Cancer is a rising problem across Southeast Asia. The latest data from the International Agency for Research on Cancer in 2020 found that there were over 1 million new cases of cancer in Southeast Asia and almost 700,000 deaths. Based on this same database, this number is expected to rise steadily over the next few years to 1.6 million.
But these statistics alone don’t tell the full story. Historically, in many parts of Southeast Asia, receiving a cancer diagnosis has been disastrous for patients and their families. In 2015, a landmark longitudinal study that followed 9,513 cancer patients across the region found that over 75 percent of patients experienced death or financial catastrophe within a year of their diagnosis. Of the patients that did survive the first year after their diagnosis, 44 percent of people had used their entire life savings to fund their treatment.
Take as an example the story of Cambodian cancer patient Oun Retra. She was diagnosed with colon cancer in 2017 and chose to go to Thailand to receive treatment due to the limited treatment options available in her own country. Her family ultimately spent more than $40,000 on several rounds of chemotherapy in Thailand. Sadly, her treatment stopped with the start of the COVID-19 pandemic and Retra died in November 2020.
Despite these dire financial and health outcomes for people across this region, cancer is still not being prioritized in public health debates and on national health agendas in most Southeast Asian countries. This is an issue on which all of the member states of the Association of Southeast Asian Nations (ASEAN) need to come together, to pool their resources to address this devastating problem.
Limited Access to Cancer Medications
Health systems in many Southeast Asian countries face wide-ranging challenges when it comes to diagnosing and treating cancer. One issue that is particularly pressing for ASEAN member countries is the lack of access to cancer drugs, whether due to pure shortage issues, or due to the high costs associated with these medications.
A 2016 global survey-based study reported that access to newer drugs is often limited across Southeast Asia. The lack of accessibility and availability of new medicines has had a negative impact on patient outcomes in the treatment of common cancers such as breast, colorectal, and lung cancer, which are together responsible for more than a third of the deaths in Asia.
Thailand and Malaysia are both considered to have relatively good medical infrastructure in place. However, cancer patients in these two countries still have limited access to innovative therapies and cutting-edge medicines, while other new treatment paradigms are limited, placing a cost burden on patients and their families. For example, researchers have found that a lack of access to pertuzumab, a monoclonal antibody drug used to treat patients with HER2 Positive breast cancer, had a serious impact on patient outcomes in many Southeast Asian countries. Researchers found that lack of access to this drug alone had led to a loss of 15.7 months of median survival time.
Meanwhile, the situation in the Philippines illustrates another aspect of this problem. The medications used to treat HER2 Positive breast cancer are technically available on the market, but the cost of these drugs renders them practically inaccessible for the majority of patients.
Shortages of cancer medicines have been reported to be most severe in Myanmar and Malaysia. The dominant reported barrier to access was a lack of reliable supply of these drugs, especially because of a lack of commercial interest for suppliers to enter and remain in these national markets. These barriers limit cancer patients’ ability to access treatment through newer drugs and if these medications are available, there is generally a high out-of-pocket cost.
In Cambodia, obtaining chemotherapy drugs at an affordable price remains a challenge, according to Dr. Katherine Tarlock, MD, volunteer for the Health Volunteers Overseas (HVO), a U.S.-based nonprofit program. Dr. Ben Watkins, MD, another volunteer in the HVO program, explained that because of the costs associated with these cancer drugs, clinicians are often forced to make difficult decisions, foregoing the most up-to-date treatment protocols because introducing those drugs to Cambodia for cancer patients would impose too great a financial burden.
Meanwhile, in Vietnam, geographic disparities that result from the country’s mountainous terrain have presented a challenge, making it hard to distribute chemotherapy drugs and services to provincial hospitals. Moreover, limited up-to-date drug supplies are also a concern. Targeted therapies and the newest drugs which treat certain types of cancer are available only at the National Cancer Hospital in Hanoi and are unaffordable to most Vietnamese, even with subsidization from the government.
Minimal funding for cancer control and high costs of targeted and cytotoxic drugs (even when subsidized) are major challenges. Health insurance in Vietnam does not yet cover all fees, especially those for advanced technologies and targeted therapies.
High demand for and limited supply of cancer medications also has also given rise to unscrupulous import schemes involving fake medicines, which pose a real challenge in the region. In one prominent recent case, a former Vietnamese deputy health minister was sentenced to four years in prison earlier this year, for his involvement in the import of counterfeit cancer medications into Vietnam.
Although there might be a willingness to pursue new mechanisms which might improve access to innovative medicines with high clinical value, the current budgets and policy priorities constitute substantial barriers to more widespread access. There is not enough country-specific cancer evidence-based data, such as a country’s cancer burden and a national cancer drug list, in Asian countries that could provide the conceptual framework for “precision” policymaking.
Given the limitations of the status quo, ASEAN should seriously consider the creation of a regional cancer center, which would allow member states to study, discuss and focus on connecting with Southeast Asian cancer patients with accessible and affordable drugs.
What Can an ASEAN Cancer Center do?
Even though there is a prediction of an increase in cancer cases, there has not yet been a concerted regional effort to address this challenge head-on. An ASEAN Cancer Center is needed to respond to the lack of access to cancer drugs, whether due to market shortages or high costs.
One primary role that an ASEAN Cancer Center could play is as a convener of relevant cancer data from member countries. Evidence-based data will help policymakers in each county and in the region to design effective national cancer plans. At the moment, data on cancer rates, on the prevalence of different types of cancer, and on the demand for key medications are limited in most ASEAN countries. If we, as a region, had access to reliable data on these topics our policymakers could more effectively design responses to patient needs.
For example, policymakers might consider putting higher-demand drugs on their national drug lists, so that patients would pay less for the drugs they need the most. Clear data on medication needs would also help the countries to avoid drug shortages, which play a huge role in price increases.
An ASEAN Cancer Center could also provide the collective bargaining power to negotiate region-wide drug prices with pharmaceutical companies, rather than each country negotiating on its own. According to a 2019 study on the improvement of access to medicine, between 2000 and 2010, most ASEAN states reported an increase in cost over eight times more than the international average; for the Philippines, the figure was more than 26 times the average.
There is also clearly a large gap in purchasing power parity between ASEAN countries when it comes to cancer drugs. For instance, as of 2017 a medicine which treats bone marrow cancer and some types of lymphoma cost $3622.22 in Malaysia and $4630.12 in Thailand, whereas a targeted drug used to treat gastrointestinal cancer, cost $150.47 in Malaysia and $89.20 in Thailand. This reality further highlights the importance of ASEAN cross-border collaboration, particularly in terms of how a regional institution might influence drug price transparency and price negotiation across the region.
Lessons can be learned from the intergovernmental regional collaboration between Belgium, the Netherlands, Luxembourg, and Austria (BeNeLuxA) in 2015, which was created to jointly negotiate drug prices and to share information across borders to counter information asymmetry between purchasers and pharmaceutical companies. Following in the footsteps of BeNeLuxA, in 2017, Malta, Cyprus, Greece, Italy, Spain, and Portugal signed the Valletta Declaration, an alliance of southern EU member states, which aims to explore strategies to jointly negotiate prices of new medicines and therapies with the pharmaceutical industry.
Cancer is too big a foe for individual governments to tackle on their own. Rather, ASEAN should take a collaborative, cross-border approach. The establishment of a dedicated ASEAN Cancer Center has the potential to strengthen this region’s ability to protect patients and their families and deliver better outcomes for those dealing with this disease.