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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 Eligibility • financial barriers • Survivorship Accessibility • Palliation • linkage barriers between services with referral networks screening diagnosis treatment treatment palliation 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 Treatment Patients education Surgical castration Radical prostatectomy Infrastructure to diagnosis and treatment Curative –aim therapy PADT Multidisciplinary team management Survivorship programmes Laparoscopic surgery Radiation w/wo hormone PADT Active surveillance PSA monitoring Side-effect management Access to clinical trials Lancet Oncol 2013;14:e524-34 ACS #6a ACS #6b [CONFIDENTIAL: Working Draft 150622] 15 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. 20 Evaluate predictive biomarkers by “Liquid biopsy” Circulating tumor cells Cell-free DNA Exosome Hegemann M et al. BJU Int 2015 exosomal protein, miRNA 21 AR-V7 Status matters for “precision” drug choice AR-V7 (+) 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 • What matters most? • choice • option • preference • value –責任 Localized prostate cancer surgery UHC for cancer in Asia • Diversity • Resource stratification • Public awareness, prevention • Evaluation and appraisal • Precision Medicine • Select appropriate population • Shared decision making • Respect value