ECCO Potential price reductions for cancer medicines ...

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Background: The majority of cancer diagnoses occur in low and middle income countries, where there were an estimated 14 million incident cases in 2012, and ...

Potential price reductions for cancer medicines on the WHO Essential Medicines List

Abstract #1032; Poster #151

Correspondence to: Dr Andrew Hill, Department of Pharmacology and Therapeutics, Liverpool University, UK [email protected]

Melissa Barber, Centre of Development Studies, Cambridge University, Cambridge, UK; Dzintars Gotham, Faculty of Medicine, Imperial College London, London, UK; Andrew Hill, Department of Pharmacology and Therapeutics, Liverpool University, UK.

Background: The majority of cancer diagnoses occur in low and middle income countries, where there were an estimated 14 million incident cases in 2012, and a projected 22 million cases by 2035.1 Global spending on oncology reached $100 billion in 20142. High prices of cancer treatments are a barrier to access in low and middle income countries, where monthly prices often exceed annual incomes.3

Over 17 million people with HIV/AIDS are on treatment with low-cost generic antiretrovirals. We investigated the feasibility of similar price reductions in medicines for cancer. The World Health Organization’s Essential Medicines List (WHO, EML) lists 39 cancer medicines that are a high priority for treatment worldwide. The cost of active pharmaceutical ingredient (API) is a central component of drug cost of production.

Table 1. Cost-based estimated generic price of tablets and current prices in India, Spain, UK, and USA Current price per tablet (USD)

Medicine

allopurinol anastrozole Methods: Current unit prices in the UK, Spain, and India were collected for cancer drugs in the WHO EML using public databases. Data on per-kilogram cost of exported API azathioprine were retrieved from an online database of Indian export logs, and used in an established costing algorithm to derive estimates for generic prices (‘target prices’) assuming robust capecitabine competition: per-dose API costs were calculated, to which excipient costs of US$2.63 per kg of finished pharmaceutical product and per-tablet costs of production of US$0.01 were ciclosporin added, plus a 10% profit margin accounting for a 26.6% average tax on profits (assuming manufacture in India.) cyclophosphamide etoposide Results: Calculated target prices for tablets were median 1% above prices in India, 85% below current prices in the UK, 89% below prices in Spain, and 86% below prices in US (Veterans Affairs pricing) (see Table 1). For injectable formulations, the lowest current price found for finished pharmaceutical products in India were median 12% above the imatinib estimated cost of API, and 94% above final product current prices in Spain, 98% above prices in the UK, and 87% above prices in the US (Veterans Affairs pricing) (see Table 2). mercaptopurine methotrexate Conclusion: Mass production of cancer drugs on the World Health Organization Essential Medicines List could significantly lower prices. tamoxifen Significant reductions in cancer drug prices could allow substantial expansion of cancer treatment coverage, across a wide range of countries.

Azathioprine 50mg tablet

Example: Cost-based generic price of Imatinib

$0.60 $0.20

$0.20

Medicine

$0.57

UK

USA (VA)

injection

600mg/60mL

$17.24

$23.94

ciclosporin

50mg/1mL

$0.07

$1.80

cisplatin

concentrate for injection injection

100mg/100mL

$3.89

$5.40

cyclophosphamide

powder for injection

500mg

$0.78

$0.53

cytarabine

powder for injection

100mg

$0.13

$0.05

dacarbazine

powder for injection

100mg

$0.34

$1.07

daunorubicin

powder for injection

50mg

$1.71

$2.91

docetaxel

injection

40mg/mL

$5.42

$3.04

$154.28

doxorubicin

powder for injection

50 mg

$2.26

$1.19

$23.95

$118.82

$13.16

etoposide

injection

100mg/5mL

$0.85

$1.02

$8.82

$14.95

$6.63

$0.18

gemcitabine

powder for injection

1g

$4.37

$4.95

$76.67

$201.01

$49.50

$0.16

ifosfamide

powder for injection

2g

$2.62

$4.89

$233.84

$61.94

irinotecan

injection

500mg/25mL

$0.12

$2.13

$112.50

$781.63

$100.97

methotrexate

powder for injection

50mg

$0.10

$4.05

$0.28

$3.41

$0.87

oxaliplatin

injection

200mg/40mL

$0.08

$356.76

$815.10

$7.47

oxaliplatin

powder for injection

100mg

$0.06

$6.39

$6.52

$202.28

$389.35

$3.74

paclitaxel

powder for injection

6mg/1mL

$0.04

$0.04

$2.60

$0.80

rituximab

injection

500mg/50mL

vinblastine

powder for injection

10mg

$2.58

$1.80

$14.04

$22.10

vincristine

powder for injection

5mg

$2.66

$0.25

$24.89

$85.67

$0.37

$247.74

$3.00 $2.56 $2.50

$200 $150

$1.50 $84.36

$1.00

$57.53 $50 $0

$0.40

$0.50 $1.04

$0.22

Cost-based generic estimate

India

Spain

UK

USA (VA)

$0.00

India

Spain

UK

$0.03

$0.03

Cost-based generic estimate

India

USA (VA)

$0.19

$0.14

$2.00

$100

Cost-based generic estimate

$0.20 $3.14

$250

$0.00

$0.05

Tamoxifen 20mg tablet

$3.50

$0.13

$0.14

$0.04 $0.02

$0.02

$0.01

$0.00 Spain

UK

USA (VA)

Dosage

carboplatin

$0.10

Spain

Formulation

Cost of API Final product current price per injection (USD) per dose India Spain UK USA (VA) $194.40

Mercaptopurine 50mg tablet

Imatinib 400mg tablet

$300

India

$87.14 $247.74 $0.40 $0.10 $0.14

$10.85

$0.05

Cost-based generic estimate

$0.08 $0.20 $0.09 $8.89 $0.37

180mg/2 mL

$0.20

$0.00

$0.04 $0.06 $0.05 $1.58 $0.57 $0.90 $11.34 $84.36 $2.56 $0.08 $0.13

injection

$0.09

$0.02

$0.11 $2.41 $0.20 $1.52 $0.49 $0.19 $8.65 $57.53 $3.14 $0.09 $0.19

USA (VA)

bendamustine $0.32

$0.03

$0.02 $3.68 $0.02 $0.24 $0.32 $0.01 $1.50 $0.22 $0.03 $0.01 $0.01

UK

100mg

$0.30

$0.05

Spain

powder for injection

$0.40

$0.10

India

azathioprine

$0.49

$0.50

$0.15

300mg 1mg 50mg 500mg 25mg 25mg 100mg 400mg 50mg 2.5mg 20mg

Cost-based generic estimate $0.02 $0.07 $0.03 $0.24 $0.05 $0.06 $0.97 $1.04 $0.03 $0.24 $0.02

Table 2. Cost of API for injectable formulation per dose and final product current prices in India, Spain, UK, and USA

Ciclosporin 25mg tablet

$0.25

Dosage

Cost-based generic estimate

India

Spain

References. 1. Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, cancer incidence and mortality worldwide. IARC CancerBase No. 11, 2013. http://globocan.iarc.fr 2. IMS. Developments in cancer treatments, market dynamics, patient accces and value. Parsippany, NJ, USA; 2015. 3. Knaul FM, Frenk J, Shulman L. Closing the cancer divide: a blueprint to expand access in low and middle income countries. Social Science Research Network, 2011. 4. Gelband H, Sankaranarayanan R, Gauvreau CL, Horton S, Anderson BO, Bray F, Cleary J, Dare AJ, Denny L, Gospodarowicz MK, Gupta S. Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: key messages from Disease Control Priorities. The Lancet. 2016 May 27;387(10033):2133-44.

UK

USA (VA)

$0.04

$12.77

$336.89

$31.63

$39.99

$160.81

$338.00 $3.02

$5.85

$65.29

$13.36

$12.56

$260.30

$2.81

$5.45

$0.74

$5.32

$11.70

$3.32

$36.87

$211.25

$37.81

$28.82

$458.14 $1,135.10 $2,661.07

Blank: no data. Prices greater than 3x cost-based generic estimate price (tablets) or API cost (injectable formulations) are in red. Prices greater than 10x are bolded.

$32.29