By Michael Galvin, Ph.D., Senior Vice President, GfK V2
Global oncology marketing research, like research in any highly specialized therapeutic area, presents a variety of challenges. As with domestic oncology marketing research, it is crucial to have a project manager and/or moderator who is familiar with the basic terminology and concepts of oncology and who understands the culture of oncologists. Oncology marketing researchers must also consider several additional factors when conducting global research.
Unlike the United States, where medical oncologists or hematologist/oncologists manage medical therapy for virtually all cancers – hormone-sensitive prostate cancer being a notable exception – the management of cancer outside the United States is more fragmented. The most obvious difference is the distinction between medical oncology and hematology: Outside the United States, with one exception, solid tumors and liquid tumors are managed by different specialists (medical oncologists and hematologists, respectively). The exception is Germany, where some physicians in private practice treat both solid tumors and common, relatively uncomplicated blood cancers (such as lymphomas and chronic leukemias).
In the United Kingdom, so-called clinical oncologists must be considered for research into the more common solid tumors. These physicians combine the function of radiation oncologist and medical oncologist: They administer radiation, but also give medical therapy (i.e., chemotherapy and targeted therapy). They typically have less specialized expertise than medical oncologists to whom they tend to refer more complicated patients.
Specialists other than oncologists can also be involved in the management of cancer. In Japan, tumors are treated by the relevant “body part specialist,” so breast cancer is treated by breast surgeons, lung cancer is treated by thoracic surgeons, and so forth. Not only does this complicate recruiting, but awareness of medications used in other tumors is relatively low in Japan. So, for example, a thoracic surgeon may not necessarily be familiar with medications used to treat breast cancer that are being studied in lung cancer. In Europe, too, body-part specialists may be involved in the management of cancers. For example, some dermatologists in Germany administer chemotherapy for skin cancer, and in Italy adjuvant therapy for skin cancers is typically administered by dermatologists rather than oncologists.
The structure of a given health care system has a significant and obvious effect on the practice of oncology. Oncologists and hematologists throughout the world tend to work in hospital-based clinics, with medications obtained and administered through nursing services and outpatient infusion centers. The United States and Germany are exceptions. In both cases, oncologists often work in private clinics, and in the United States, oncologists in private practice represent the majority of oncologists. This can affect the practice of oncology in several ways – in Germany, for example, oncologists in private practice tend to see uncomplicated cases – but most notably in terms of how medications are administered in the United States.
Marketing researchers also need to recognize the power of guidelines. In the United Kingdom, in particular, oncology and hematology are practiced according to regional guidelines, leaving little variation from physician to physician.
The system of reimbursement for health care can also affect the practice of oncology. Generally speaking, oral medications are generally preferred to intravenous ones on the basis of patient convenience and acceptability; however, in the United States, oncologists have a strong preference for intravenous medications, in part because they generate revenue for their practices. In contrast, oral medications often require significant unreimbursed staff time to secure prior authorizations or reimbursement.
Newer, more expensive agents may not be as widely available in certain countries, either because of lack of funding in emerging markets such as Brazil, Russia and Mexico, or because of strict cost-benefit accounting in countries such as Germany and the United Kingdom. In my experience, oncology medications are the most available, and carry the least restrictions on use, in France and the United States.
It is important to keep in mind that systems that combine significant private and public components – such as Mexico and the United States – can see variable use of oncology medications according to the system in which the patient participates. Generally speaking, patients in the private system in Mexico have wider access to newer antineoplastic agents than their compatriots in the public system. And of course, in the United States, until recently, Medicare offered no coverage for oral medications, making them, practically speaking, unavailable for patients over the age of 65.
As one might expect, even in the context of large, international, multicenter studies, the standard of care for a given cancer can vary both within and among countries. These variations can be due as much to some of the environmental factors mentioned above as to differences in culture. For example, the European standard of care for advanced non-small lung cancer patients who have good performance status has until recently been cisplatin and gemcitabine. (The European physicians with whom I have spoken tend to consider the U.S. standard – carboplatin and a taxane, usually paclitaxel – an inferior regimen.) However, cisplatin and navelbine are reportedly widely used in France and Poland, and I was told that many physicians in the United Kingdom use carboplatin instead of cisplatin because carboplatin – which has a shorter infusion time and requires less premedication – can be given in the outpatient setting, thereby saving money and hospital resources. Oncology marketing researchers thus need to uncover and explain these differences to provide appropriate advice to our clients.
A related issue, particularly from the point of view of designing and interpreting clinical trials, is the widespread use of medications in one country that are not available in other countries. These can sometimes be newer generation biologics – for example, Avastin (bevacizumab) is not available for lung cancer or breast cancer in the United Kingdom – but they can also be older chemotherapies that lack a champion with resources to develop them in other markets. For example, the chemotherapy fotemustine, which is widely used for the treatment of melanoma and glioma (primary brain cancer) in continental Europe, is unavailable in the United States and the United Kingdom. Similarly, some agents available in North America and Europe may not be available in Japan and South Korea.
Like other specialties, oncology has its own distinct culture – in this case, highly clinical-data driven and disdainful of overt marketing – but even so there are important differences among the countries usually included in global marketing research.
In my experience, oncologists and hematologists are more aggressive – by which I mean they tend to use more toxic regimens in the hopes of achieving response – in France than elsewhere in Europe or the Americas. In contrast, oncologists and hematologists tend to be more conservative in the United Kingdom and Germany, perhaps due in part to the financial constraints they face. Oncologists and hematologists in southern Europe and Latin America, as with all physicians in these countries who participate in marketing research, tend to have more positive views of new treatments, concepts, and marketing messages than their colleagues elsewhere.
