Choosing Wisely, Researchers Look at Access to Essential Cancer Drugs on a Global Scale

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According to the International Agency for Research on Cancer (IARC), an estimated 19.3 million new cancer cases occurred worldwide in 2020, resulting in almost 10 million deaths. The IARC projects a 50% rise in global cancer incidence and mortality by 2040. To help control this looming crisis, equitable distribution of cancer therapeutics is essential, especially in the developing world, where costs of new cancer agents pose considerable barriers to access.

To that end, the WHO Essential Medicines List, which identifies priority medicines for public health, has included a growing list of oncology drugs. A recent study in The Lancet Oncology looked at whether the cancer therapeutics in the Essential Medicines List were aligned with the needs of oncologists worldwide.1

WHO Essential Medicines

Christopher M. Booth, MD, FRCPC

Christopher M. Booth, MD, FRCPC

The study’s lead author, Professor Christopher M. Booth, MD, FRCPC, a medical oncologist and researcher at Queen’s University Cancer Research Institute in Ontario, Canada, became involved in global oncology after spending a sabbatical in India in 2016. For the past few years, Dr. Booth, who is the Canada Research Chair in Population Cancer Care, has served on the WHO Essential Medicines List Cancer Medicine Working Group, which provides advice to the WHO about which cancer medicines should be prioritized by governments and health systems worldwide.

Asked to shed light on the WHO’s Essential Medicines List, Dr. Booth said: “Since 1977, the WHO updates and releases an Essential Medicines List (EML) every 2 years. This list helps policymakers and health-care systems worldwide prioritize which medicines to provide for patients. The rationale is to help countries better assess which medicines they should allocate their resources to, in order to more equitably serve their general population. In the review process, a panel of experts examine the benefits, harms, affordability, and feasibility of new drugs. I serve on the EML’s Cancer Medicine Working Group, and we reviewed all of the oncology drug applications and provided our advice to the expert selection committee.”

Dr. Booth noted that the Essential Medicines List for cancer medicines went through a major update in 2015. In prior iterations, it was used to list newer cancer medications, until the committee realized that many older drugs were not included, prompting the update.

“There is a huge amount of deliberation about which drugs should be added. The EML is a global tool; however, many high-income countries have their own processes for health technology assessment (HTA). Accordingly, the EML may be most useful for countries that do not have their own processes for HTA; these are predominantly middle- and lower-income countries,” said Dr. Booth. “A number of us have wanted to look beyond the EML as a tool to ensure equitable global access to cancer drugs, out of which came the Desert Island Project: Global Access to Essential Cancer Medicines.”

Three Objectives of the Desert Island Project

Dr. Booth explained that the Desert Island Project study had three questions to answer: (1) Which medicines do front-line oncologists consider the most important? (2) Does the Essential Medicines List reflect these high-priority medicines? (3) Are these medicines available to patients in routine care?

Top 20 Most Commonly Selected Cancer Medicines: From Global Survey of 948 Oncologists

1. Doxorubicin

2. Cisplatin

3. Paclitaxel

4. Pembrolizumab

5. Trastuzumab

6. Carboplatin

7. Fluorouracil

8. Tamoxifen

9. Capecitabine

10. Cyclophosphamide

11. Docetaxel

12. Oxaliplatin

13. Dexamethasone

14. Nivolumab

15. Rituximab

16. Imatinib

17. Gemcitabine

18. Etoposide

19. Osimertinib

20. Letrozole

Info from Fundytus A et al.1

To gather data for the study, Dr. Booth and his team surveyed 948 front-line oncologists from 82 countries. The following scenarios was presented to these physicians: “Imagine your government has put you in charge of selecting anticancer medicines for your country. You are allowed to select a maximum of 10 medicines that will be available to treat all cancers in your country. Which drugs would you recommend to the government to achieve the greatest benefit for the most patients? Assume that cost (system and patient) is not an issue and that you have access to the necessary supportive care medicines, diagnostics, and laboratory services.”

Conventional Drugs Still Play an Important Role

The research team found that most high-priority medicines identified by oncologists are older, inexpensive chemotherapy and hormone medicines. With one exception, all of the top 20 high-priority cancer medicines are already included on the Essential Medicines List (see sidebar). Oncologists consider these medicines to be the most important because they have large benefits for patients across many common cancers.

Coauthor of the study, Professor Manju Sengar, MD, of the Department of Medical Oncology, Tata Memorial Centre, Mumbai, India, spoke with The ASCO Post: “Our study highlighted that even though most of the drugs selected by the oncologists were old, inexpensive, and conventional cytotoxic drugs, the access was really poor in low- and middle-income countries (with the risk of catastrophic expenditure as indicated by 68% of respondents). This compromises the delivery of optimal treatment for some of the highly curable cancers. The WHO EML has the potential to act as a ready reference to assist low- and middle-income countries in the selection of relevant drugs for their national health schemes. The inclusion of a drug in EML can facilitate price negotiation and improve the affordability of cancer drugs.”

According to the researchers, the most surprising, and sobering, finding was that even older, generic, inexpensive chemotherapy drugs remain out of reach for most patients globally due to cost. “This is tragic, as many of these medicines have a huge impact on patient survival,” Dr. Booth noted. “The oncology community and the general public should not tolerate a system in which the country into which you are born will largely dictate your chances of surviving cancer. We can do better than this.”

Oncology Community Needs Solidarity

The process by which the expert committee judges medicines for inclusion on the Essential Medicines List is a public one; in addition to peer review, the committee considers comments from a wide range of entities before making its recommendations. To make the process more transparent in the future, the WHO Essential Medicines List Secretariat, ­Lorenzo Moja, MD, MSc, DrPH, PhD, is working on digitizing the list and the evidence that has gone into the expert committee’s recommendations.

Dr. Moja commented: “I congratulate the oncology clinical community for efforts in developing guidelines that emerge the merits of cancer medicines associated with large clinical benefits. Although guidance is becoming more selective, WHO sees still too many countries misspending money in several cancer medicines of scarce value. WHO set a clear bar for benefit: a survival benefit of 4 to 6 months is the minimum threshold to adopt novel cancer medicines in clinical practice.”

The research team hopes that data from its study will highlight the enormous challenges faced by patients with cancer worldwide who cannot access essential oncology medicines because of prohibitive costs. “The oncology community needs to speak in solidarity and work with health system leaders to change the way in which cancer medicines are purchased and distributed. We can learn from our colleagues in the HIV community, who faced similar problems decades ago—through advocacy and by using a variety of policy tools, they were able to make HIV medicines more affordable for patients worldwide,” said Dr. Booth. 

DISCLOSURE: Dr. Booth, Dr. Sengar, and Dr. Moja are members of the WHO Essential Medicines List Cancer Medicine Working Group.


1. Fundytus A, Sengar M, Lombe D, et al: Access to cancer medicines deemed essential by oncologists in 82 countries: An international, cross-sectional survey. Lancet Oncol 22:1367-1377, 2021.