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Kyung Hae Jung Asan Medical Center
Seoul, Korea
Medical insurance system in Korea
Current evidence and real management
for breast cancer patients in Korea
Only one provider, Government
(National Health Insurance Corporation)
All people have mandatorily joined the
medical insurance policy since 1989
Public
institution
Private
institution
93%
Is meant for all the hospital or
organization for medical treatment not to
reject application of medical insurance
but to offer an appropriate medical care
to the patients.
OECD Health Data 2012
‘2012
OECD 9.3%
Korea 7.5%
‘2002
OECD 8.0%
Korea 4.8%
‘2012
OECD 6.7%
Korea 4.2%
OECD Health Data 2012
Korea
OECD av.
‘2002
OECD 5.7%
Korea 2.6%
Health & Welfare Policy Forum 2013;196:89-102
OECD Health Data 2011
Level of evidence : Category 1
No drug for replacement or substitution
No increase in financial burden for
provider
But, cancer patients pay only 5% of all
medical cost if covered by insurance
Usually they are provided with good
quality cancer care with low economic
burden.
4.9
9.7
10.8
15.7
18.6
22.5
20.8
20.0
21
.1
25.6
19.4
21.2
19.8
18.9
24.3
23.1
22.9
27.0
23.9
25
.4
23.6
27.2
25.8
24.5
28.8
24.6
27.0
30.6
29.4
30.5
31.5
33
.4
6.1
10.8
11.4
13.4
16.4
17
.4
17.7
18.1
18.5
18.6
19.1
19.1
19.3
19.7
19.7
19.8
19.8
19.9
20.3
21.0
21.4
21.6
22.1
22.3
23.2
23.6
24.1
24.7
25.0
25.6
26.1
28.6
0
5
10
15
20
25
30
35
2000 2009Age-standardised rates per 100 00 females
OECD Health Care Quality Indicators
OECD 22.9% 19.8%
Korea 4.9% 6.1%
Korea Central Cancer Registry, 2010
Thyroid Stomach
Colon Lung
Liver Prostate Biliary
Pancreas NHL
Breast
Trial N ORR TTP/PFS
(months)
OS
(months)
von Minckwitz et al. (2009)
Capecitabine
Capecitabine+Trastuzumab
156
27%
48.1%
TTP
5.6
8.2
P=0.03
20.4
25.5
P=0.26
Geyer et al. (2006)
Capecitabine
Capecitabine+Lapatinib
324
14%
22%
P=0.009
TTP
4.4
8.4
P<0.001
Blackwell et al (2010)
Lapatinib
Lapatinib+Trastuzumab
296
6.9
10.3
P=0.46
8.4 wks
12 wks
P=0.008
39 wks
51.6 wks
P=0.016
Beyond progression during or within 1
year of adjuvant trastuzumab, physicians
have to change to lapatinib/capecitabine in
HER2-positive metastatic breast cancer.
And then, no anti-HER2 targeted agents
are allowed anymore.
Anderson M et al. JCO 2011;29:264-271
HERNATA study:1st line
Trastuzumab/Docetaxel vs.
Trastuzumab/Vinorelbine
Anderson M et al. JCO 2011;29:264-271
HERNATA study:1st line
Trastuzumab/Docetaxel vs.
Trastuzumab/Vinorelbine
More Gr ¾ toxicities in Docetaxel arm :
Febrile neutropenia (36.0% vs 10.1%)
Leucopenia (40.3% vs 21.0%)
Infecttion (25.1% vs 13.0%)
Fever (4.3% vs 0%)
Neruopathy (7.9% vs 0.7%)
Edema (6.5% vs 0%)
Trastuzumab combined with taxane is the
only one regimen allowed to use and
reimburssed.
Other combinations in current NCCN
guideline, such as trastuzumab with
vinorelbine, capecitabine, or lapatinib
should not be used.
Pertuzumab (Perjeta)
Activates antibody-dependent cellular cytotoxicity
Inhibits HER2-mediated signalling
Inhibits shedding and, thus, formation of new p95
Inhibits HER2-related angiogenesis
Hubbard 2005
Trastuzumab
Pertuzumab
Activates antibody-dependent
cellular cytotoxicity
Prevents receptor dimerization
Potent inhibitor of HER2/HER2-
and HER2/HER3-mediated
signalling pathways
Baselga et al. N Engl J Med 2012;366:109-
19.
At 30 months median follow up
Baselga et al. N Engl J Med 2012;366:109-19.
Monoclonal antibody: trastuzumab
Target expression: HER2
Highly potent chemotherapy
(maytansine derivative)
Cytotoxic agent: DM1
Systemically stable Breaks down in target cancer cell
Linker T-DM1
(Kadcyla®
)
Verma et al, N Engl J Med
2012;367:1783-91
ORR : Cape/Lap : 31%, T-DM1 : 44%, p<0.002
Verma et al, N Engl J Med 2012;367:1783-91
Verma et al, N Engl J Med 2012;367:1783-91
Wildiers H, SB Kim et al, ECCO 2013
New anti-HER2 targeted agents,
pertuzumab and T-DM1, are not available
now.
Outlook of their reimbursement in the near
future is very dim.
Lancet 2011; 377: 914–23
PFS OS
13.2 vs 10.5m 3.7 vs 2.2m
2012 SABCS
New drugs for patients with HER2-
negative cancer are very expensive and
not reimbursed, yet.
Eribulin ca 4,000 USD/cycle
Everolimus/Exemestane ca 2,700 USD/month
Less than 5% of patients indicated are
treated with these drugs.
aHormone receptor-positive patients receive adjuvant tamoxifen; AP, doxorubicin 60 mg/m2, paclitaxel 150 mg/m2; H, Herceptin® 8 mg/kg loading then 6 mg/kg; LABC, locally advanced breast cancer; P, paclitaxel 175 mg/m2; q3w, every 3 weeks; q4w, every 4 weeks
HER2-positive LABC
(IHC 3+ and / or FISH+)
n=118
H + AP
q3w x 3
H + P
q3w x 4
H q3w x 4
+ CMF q4w x 3
Surgery followed by
radiotherapya
H continued q3w
to Week 52
P
q3w x 4
CMF
q4w x 3
Surgery followed by
radiotherapya
n=117
AP
q3w x 3
AP
q3w x 3
P
q3w x 4
CMF
q4w x 3
Surgery followed by
radiotherapya
n=99
HER2-negative LABC
(IHC 0/1+)
19(16%) patients crossed to
H after November 2005
Gianni, et al. Lancet 2010;375:377
Reveals a significant interaction (p=0.037) of
treatment and pCR
EFS benefit from trastuzumab is significantly linked to
pCR, and almost restricted to pCR
pCR with trastuzumab is linked to significant EFS
benefit, while association of pCR and EFS is smaller
and non significant without trastuzumab
The regimen used in NOAH trial is the
only one approved as neoadjuvant
treatment in HER2-positive breast cancer.
But it’s not reimbursed now.
How do patients feel in current
medical environment in Korea?
Health & Welfare Policy Forum 2013;196:89-102
Unm
et needs (%
)
Unm
et needs (%
)
% of out-of-pocket payment % of out-of-pocket payment
Patients and doctors in Korea have many obstacles to access to modern &/or expensive drugs proven to increase clinical outcome and feel uncomfortable.
We need more information on predicting benefits and toxicities of treatment in individual patient.
Consensus and wisdom are eagerly needed for fair distribution of limited medical resources.
Thank you for your attention !
....???
1997-2002 2004-2009
OECD (17) 78.7 83.7
Korea 76.7 82.2
Japan 86.1 87.3
Singapore 68.7 78.5
67.9
68.7
70.8
72.3
79.3
75.0
76.2
76.7
82.7
82.8
74.5
78.7
79.5
77.0
83.1
84.2
82.4
85.6
86.1
88.6
73.0
76.9
78.5
78.6
80.3
81.2
81.3
82.0
82.0
82.2
0.0
83.3
83.7
84.4
84.5
86.0
86.1
86.2
86.3
86.3
86.5
86.6
87.3
89.3
0 20 40 60 80 100 120
Latvia
Slovenia
Singapore
Czech Republic
Ireland
Austria
United Kingdom
Denmark
Portugal
Korea
Malta
France
Germany
OECD (17)
Netherlands
New Zealand
Sweden
Israel
Belgium
Iceland
Finland
Norway
Canada
Japan
United States
Age-standardised rates (%)
2004-2009 1997-2002
Ministry of Health & Welfare
Insurance
subscribers
Medical institution
Health Insurance
Review &
Assessment Service
National
Health
Insurance
Corporation
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