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Big Debate 1 - Tuesday 2 October
Topic: Cancer societies can engage with the pharmaceutical industry without compromising their independence
Debator - Against
Prof. Richard Sullivan
Debator - For
Oncology drugs produced by the pharmaceutical industry are a central plank in the platform of evidence based cancer treatment strategies in common use for more than half a century. Ongoing trials are conducted for the purpose of finding better more effective agents with which to treat cancer.
There is by necessity a close working relationship between cancer doctors and researchers and the industry that develops and produces the drugs they prescribe. Leading oncologists and researchers participate in the design and conduct of clinical trials in striving for better patient outcomes.
While cancer drugs are vital medicines, there is a, competitive, profitable and growing market for oncology pharmaceuticals. One estimate suggests the combined value of sales of the top ten oncology drugs worldwide exceeded $US 43.7Billion. Three of the largest multinational pharmaceutical companies have a combined market capitalisation of $US 474Billion.
With such enormous amounts of money, much of it public money spent through the worlds’ government funded health systems involved, there has been increasing pressure to ensure proper controls are in place to maximising health outcomes rather than company profits are the dominant driver for decision making related to oncology drugs. Should cancer societies give consideration to challenging question of value for money when it comes to drugs? If so, how?
With competitive markets come active product marketing practices. There are benefits to pharmaceutical companies to have, and to be seen to have relationships with cancer charities which develop strong credible reputations advocating for the interests of cancer patients. The resources of the pharmaceutical sector are beneficial to cancer societies to allow us to fund activity that might otherwise be difficult to fund.
A common scenario is when cancer societies are approached by patient groups or by pharmaceutical companies directly to advocate for specific oncology drugs to be added to lists of publicly funded drugs.
How are cancer societies able to independently assess such approaches to ensure improvements for cancer patients are commensurate with the requested public investment? How do cancer societies ensure they maintain their independence, and be seen to be independent in the eyes of government, in such circumstances?
Some people express concern that financial relationships between cancer societies and ‘Big Pharma’ result in a loss of independence by cancer charities, with a worst case depicted that cancer charities can become ‘puppets’ of a multinational industry driven by maximising sales and profits.
If any relationship is established between cancer societies and pharmaceutical companies, how are these and related conflicts of interest managed?
Big Debate 2 - Wednesday 3 October
Topic: Should doctors support their patients’ choice to take unproven treatments?
Debator - Against
Debator - For
With an increasing focus on holistic cancer treatment, integrative medicine is gradually practiced in cancer care. Therapies such as acupuncture, Reiki, Yoga, and meditation are now accepted and endorsed by many conventional treatment centres, and are even included in a number of clinical practice guidelines.
While these therapies are meant to fulfil a specific role: pain relief, strengthening mental health, or improving the patient’s endurance, in certain cultures, complementary or traditional therapies play a larger part for the patient. This brings on a few dilemmas:
- The accepted and proven methods are often placed in the same category with other unproven, non-peer reviewed and non-mainstream methods. Complementary or traditional treatment could cover a vast range of therapies, from a simple nutrition supplement to blood transfusion which benefits are unproven. Also, therapies that are accepted are often advertised beyond their function. One example is acupuncture being said to clear the body of toxins, when its ‘formal’ role is in palliative care.
- Patients who are challenged by low health literacy are often unable to discern between scientifically proven or anecdotal based therapies. Even the general public uses the terms alternative and complementary medicine interchangeably, and treat it as such.
Some patients, upon conflicting advice from surrounding people, depleting income or failing health, may rely more and more on these therapies, even when undergoing conventional treatment. Many are reluctant to reveal this to their treating doctors, for fear of being met with disapproval, or being advised to stop. Apart from resulting in a lack of trust and transparency between the doctor and patient, the secrecy also puts patients at risk of getting a harmful therapy.
More importantly, when pressured – or getting the impression of being pushed – to give up the unproven therapies, patients often feel they have to make a choice. Many times, out of deference and trust for therapies that have deep roots within their culture or religion, or a preference for therapies that seem to produce fewer side effects, patients give up conventional treatment altogether, and continue with the non-conventional therapies.
To encourage patient compliance, should doctors then support the patient’s choice to take these unproven, non-mainstream and non-peer reviewed treatment? Is it the treating doctor’s responsibility to ensure that the unproven therapies will not affect the efficacy of the conventional therapy? What happens when patients who have no access to conventional treatment choose to go for unproven therapies only?
Big Debate 3 - Thursday 4 October
Topic: Does HPV vaccination trump early detection in decreasing cervical cancer mortality?
|Debator - Against||Debator - For|
Cervical cancer is a global problem that particularly affects women in low-and-middle income countries where it is the leading cause of cancer mortality. This seems paradoxical given that there is a definite etiology for its occurrence (HPV infection) - a well defined tumour progression model with a long latent period - the presence of an effective screening test and the fact that the cervix lends itself to easy examination. Unfortunately the majority of countries where cervical cancer is an issue lack effective screening programs resulting in late diagnosis and increased mortality.
Two vaccines against infection by oncogenic HPV subtypes have been introduced in population based vaccination strategies in many countries in the recent past. Although conceptually attractive given that it could be an alternative to screening, the vaccine has not gained universal acceptance. Sceptics voice concern of lack of robust data to support the duration of immunogenicity, duration of follow-up in trials, endpoints chosen for efficacy and well as the side effects associated with their use. Given these limitations as well as the associated costs they cite that vaccination may not be a cost effective strategy in countries with limited resources and cannot replace the setting up of effective population based seeing programs.
Those in favour of vaccination cite that current rates of women at risk of dying of cervical cancer is unacceptably high and many of these can be prevented by early introduction of vaccination as establishing screening programs in many countries will take time given the lack of infrastructure and resource constrains. Screening guidelines will in all probability also change with the introduction of the nonvalent vaccine that will cover a higher proportion of cancers than the vaccines currently available. Costs barriers can be overcome through different funding models and support from organisations like GAVI and PAHO. Over 200 million doses have been administered worldwide with no serious cause of safety concerns.
Therefore, there seems to be an urgent need to settle the equipoise with regards the benefits of vaccination over establishing screening programs in countries that currently lack them. Issues to be addressed will revolve around costs, robustness of scientific evidence, and the earlier impact of either strategy.