Clinical evaluation of UHC for cancer HOW CAN WE MOBILISE ACTION TO REALISE UHC IN ASIA? Clinical evaluation of UHC for cancer Shigeo Horie, M.D., Ph. D. Department of Urology Juntendo University Graduate School of Medicine

3 objectives of UHC Equity in access to health services those who need the services should get them, not only those who can pay for them Quality of health services Being good enough to improve the health of those receiving services Financial-risk protection ensuring that the cost of using care does not put people at risk of financial hardship.

How UHC for cancer can be achieved in Asia UHC is conceptually appealing but its application will vary from one country to another given the diversity of country levels of economic development, health system resources and epidemiological challenges. It is important to identify ways of measuring UHC across countries that are comparable but adaptable to local contexts. MEASUREMENT AND MONITORING OF UNIVERSAL HEALTH COVERAGE WHO summary report 2013

Breast cancer survival is a key indicator for UHC in cancer control How countries are covering prevention, care, and treatment of cancers. a focus on women the need for well-trained health workers and functioning infrastructure including laboratory capacity, an adequate stock of medicines, and radiation equipment.

Fundamental barriers to UHC of cancer care Primary prevention Survivorship Palliation Eligibility financial barriers Accessibility linkage barriers between services with referral networks

screening palliation diagnosis treatment treatment rehabilitation

UHC and clinical guidelines Clinical guidelines should be stratified according to the resource availability. Resource-stratified guidelines can be utilized for bench-marking.

Treatment of clinically localized prostate cancer according to level of health-care resources Health care resource category Basic level Limited level Enhanced level Maximum level General Patients education Infrastructure to diagnosis and treatment Multidisciplinary team management Survivorship programmes Treatment Surgical castration Radical prostatectomy Curative –aim therapy PADT Laparoscopic surgery Radiation w/wo hormone Active surveillance PSA monitoring Side-effect management Access to clinical trials Lancet Oncol 2013；14:e524-34

[CONFIDENTIAL: Working Draft 150622] ACS #6a ACS #6b [CONFIDENTIAL: Working Draft 150622]

Kaplan–Meier estimates of OS in Swedish patients diagnosed with mRCC by year of diagnosis 2012 2002 M Lindskog　et al. ASCO-GU 2015

More access to drugs, longer life span International mRCC Database Consortium database  Overall survival of patients who received 1, 2, or 3+ lines of target therapy were 14.9, 21.0, and 39.2 months, respectively On multivariable analysis, 2 lines and 3+ lines of therapy were each associated with better OS (HR=0.738 and 0.626, P<0.0001). British Journal of Cancer (2014) 110, 1917–1922.

Sustainable UHC Lancet oncology 2015

PD-1 ab costs $1.9 million/month

Precision Medicine in Cancer treatment Precision medicine in oncology is focused on identifying which therapies will be most beneficial for each patient based on genetic characterization of their cancer.

Evaluate predictive biomarkers by “Liquid biopsy” Circulating tumor cells Cell-free DNA Hegemann M et al. BJU Int 2015 Exosome exosomal protein, miRNA

AR-V7 Status matters for “precision” drug choice Docetaxel (generic) AR-V7 (-) AR target medicine Antonarakis ES, et al. ;N Engl J Med. 2014 Sep 3 (e-pub)

Achieving UHC in Cancer treatment Increase survival Maintain quality of life and Reduce the disease burden

Shared decision making Localized prostate cancer What matters most? choice option preference value surgery radiation Active surveillance 責任

UHC for cancer in Asia Diversity Resource stratification Public awareness, prevention Evaluation and appraisal Precision Medicine Select appropriate population Shared decision making Respect value