Line of duty

At the HSJ medicines forum this month, the great and the good of NHS drug decision-making units gathered to give their state of the nation addresses.

NICE was represented by chief exec Sam Roberts, and one of the more striking things she said was that up to 40% of their time at the moment was spent on working through 50 different applications of the same three medicines.

Three medicines, 40% of NICE’s time, might sound extremely odd, but this is the new world we find ourselves in with complex biologics.

Often what takes the time is how to grade the ‘line’ of a medicine – obviously for disease severity or patient group type, as well as its status in combination with other drugs, but now, increasingly, for multiple disease areas.

After you’ve considered a large molecule’s ‘primary’ use, where does it sit for different branches of the pathway algorithm? And on multiple different pathways?

Pretty soon you end up with one damn complex diagram and it’s this environment that our customers, increasingly, are turning to us to help navigate.

Traditionally companies would want to – and indeed still do – buy market share data from HSJ Market Intelligence around numbers of patients in a therapy area.

Take an area like multiple myeloma. You’d want to know total numbers – say you have 10,000 patients in this broad disease category.

You would want to know how the population breaks down by trust or ICS, and you would want to know how many patients are being treated with each regimen per account.

With this kind of data, you can begin to see where your current patient population is, how your treatment is doing compared with competitors, where there are more patients who could benefit from the drug, and so on.

But the kinds of requests we receive now are getting much more sophisticated. Let’s say your MM treatment is currently prescribed fourth line. Here the initial question is, how many patients are on the 1st, 2nd, 3rd or 4th line of treatment for MM, and where are they?

Once HSJ looks at questions like these, it can return unexpected results for companies wanting to know where to focus their efforts.

It might turn up that there are 360 patients with multiple myeloma at Clatterbridge – double the number of patients compared to, say, Worcester Cancer Centre, as you’d expect for a big hub.

But it might also be that at Worcester there are 100 patients that are currently receiving treatment at third line, as opposed to Clatterbridge where there are 50.

Therefore, the potential patient pipeline for a company with a fourth line-treatment might be double in this, perhaps less well-engaged area.

In this context, it becomes less about simply knowing how many patients are currently on your treatment – and more about understanding where the highest concentration of patients whose treatment might fail at third line are.

That’s where pharma would need to concentrate its go-to-market activities. That’s where, for want of a better expression, the pipeline of future patients will come from.

With a great deal of new me-too and me-three products in the offing for this decade – particularly in the high growth area of immuno-oncology, but also in areas like atopic dermatitis and neurology – a new sophistication is needed to understand where and how the NHS can benefit from your treatment.

The need to understand usage in terms of therapy, and especially to know where the most number of patients that are progressing through successive lines of therapy are, will help pharma target where the greatest need is.

At the moment we see that patients are effectively being blocked from more innovative novel therapies because of strict NHS ‘line discipline’.

For example, in oncology a patient may need to progress through a chemotherapy regimen to receive immunotherapy.

Similarly, patients often won’t get an advanced therapy such as a MAB before they’ve failed on immunosuppressive therapies such as methotrexate.

So, our customers may now try to establish with us which Trusts have the greatest numbers of patients on immunosuppressives – and are often more concerned with understanding this type of insight than their competitors’ performance.

For if they don’t improve, they all become eligible for the more advanced and expensive therapies.

You may say the big problem here is with the regulation in the first place – if more people are responding to what is currently third line than first, has it been placed there because of clinical conservatism, or financial necessity, rather than the evidence base?

However, NICE can only work with the data it has, and therefore more patients need to come through the system having responded well to the third line for its status to change.

So the big challenge is to understand the previously treated population, to be able to be prepared to support more and more in a different line setting, and advance the more innovative treatments.

Put simply, patients will have access to the most innovative treatments earlier – and therefore will be most likely to benefit from them – if pharma knows where they are.

Patient pipeline data is another example of what we at HSJ Market Intelligence call precision data.

In the days of multiple therapy options it’s not enough to have raw numbers of your scripts or patients – or even your competitors’.

You need a detailed knowledge of where all your patients are in the pathway, how well they are being served by their current regimes, and the likelihood their journey will progress onto the treatment that will most benefit them.

As genomic and personalised medicine become more prevalent, this need for industry and healthcare systems to have such a joint overview is only going to become more acute.

It’s something government, regulators, clinicians, HTA bodies, formulary decision-makers and prescribers will need to align on, and ultimately come up with smart, patient-centric, flexible and tailored formularies.

Oli Hudson is Content Director at HSJ. Go to hsjmarketingintelligence.co.uk