Advances in treatment of LPDs has lead the way for cancer therapy since development of methotrexate in childhood ALL in late-1940s and MOPP in Hodgkin’s lymphoma (HL) in mid-1960s. Targeted therapies, especially monoclonal antibodies and small molecule kinase inhibitors, have revolutionised cancer treatment this century, but with enormous costs, unaffordable in most LMICs. Major advances, especially rituximab, which has radically changed the management of B-cell NHLs, from CLL/SLL to DLBCL, in the last 20 years, remains unaffordable in many LMICs. Approvals of newer monoclonals, further enhancing therapy of LPDs, including brentuximab and anti-PD1 immunotherapy in HL, daratumumab in myeloma and more recently anti-CD19 and anti-BCMA bispecific T-cell enhancers (BiTEs) and CAR-T-cells, are very exciting, but unaffordable in almost all LMICs.
Lack of access to vital treatments is not confined to novel immunotherapies but also involves old, previously cheap medicines, that have seen either massive price increases or “abandonment” by pharmaceutical companies. Thalidomide, developed in 1930s, later banned due to serious foetal abnormalities, was shown to be active in myeloma in 1990s. Instead of this breakthrough helping patients, thalidomide was bought by a single company with skyrocketing prices. Safer and better analogues, especially lenalidomide, are even more expensive, further restricting access in LMICS. Access to L-asparaginase, a mainstay in childhood ALL since 1960s, is becoming difficult due to limited profit margins.
The addition of rituximab to WHO EML in 2015 and by individual country EMLs, plus indications outside oncology, have improved access, although costs still remain high. Biosimilars and generics are now helping drive down prices and improve access but we still have a long way to go. Radical changes in access to all cancer therapies in LMICs is essential. We are unfortunately seeing a worldwide increase in more and more novel treatments for less and less people.