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