Heather Dalrymple is the National Clinical Lead for Cancer Medicines at Healthcare Improvement Scotland. Having worked as a Lead Cancer pharmacist, she’s now part of the National Cancer Medicines Advisory Group (NCMAG) team helping to improve national access to cancer medicines across the country.
Cancer is something which, sadly, will affect us all in one way or another. One in two of us will get a cancer diagnosis during our lifetimes, and although we can reduce our own chances of getting some cancers, there’s still a possibility that we or our close family members or friends will get a cancer diagnosis.
I know how difficult this can be. Almost six years ago, I lost my dad to mesothelioma, a type of cancer that is caused by asbestos exposure and develops in the lining of the lungs. He was treated in the hospital where I worked, which made it even harder.
At that time, there weren’t many treatment options available for mesothelioma patients, and unfortunately the chemotherapy he received did not help control his disease, and gave him terrible side effects. But now there is evidence available for new treatments with immunotherapy offering improved outcomes with reduced side effects for some patients, showing that improvements in treatment options are developing all the time for many cancers
A passion and a privilege
I spent the majority of my career working as a cancer specialist pharmacist in NHS Lothian before moving to Healthcare Improvement Scotland in May 2022.
I developed my passion for the field of cancer care whilst working as a haematology specialist pharmacist, before becoming lead pharmacist for cancer services in the Edinburgh Cancer Centre. It’s an area where there are constant improvements in the treatments than we can offer patients. In my working lifetime, the treatment options available have multiplied exponentially and outcomes for many cancers have really improved.
It has been a privilege to have been involved in shaping the development of cancer pharmacy services throughout my career, and ensuring that we can safely deliver effective Systemic AntiCancer Treatment (SACT) options for cancer patients.
The cancer community comes together
At the start of the COVID-19 pandemic I was a founding member of the COVID-19 National Cancer Medicines Advisory Group (COVID-19 NCMAG). This group, formed in response to the pandemic, was really successful in uniting cancer specialists to consider how we might best continue to deliver Systemic Anti-Cancer Treatment (SACT) to cancer patients whilst reducing risk of COVID infection in this vulnerable patient group and reducing the pressures on the service.
In a very short space of time 30 proposals were reviewed – and 20 introduced into practice. The group was extremely successful in delivering a ‘Once for Scotland’ approach for patients at a time of huge uncertainty and is something I’m proud to have been a part of.
The development of the National Cancer Medicines Advisory Group (NCMAG)
The success of the COVID-19 NCMAG in delivering national advice, led to a business case being made to Scottish Government with the aim of establishing a programme which would support equitable access to safe and effective off-label and off-patent uses of cancer medicines. This was successful and the NCMAG business as usual programme was established during 2021.
Prior to NCMAG being established, there was no consistency in decision making for cancer medicines which fell into the categories of being off-label –where a medicine is used outwith its licence and off-patent – where the patent for the medicine has expired and alternative versions are available. Off-patent and off-label uses of medicines are outside the remit of the medicines work carried out by our colleagues in the Healthcare Improvement Scotland’s Scottish Medicines Consortium (SMC). SMC review new medicines that have received a licence from the Medicines and Healthcare products Regulatory Agency (MHRA – the licensing body for the UK) and new formulations of, and new ways to use, established medicines.
How NCMAG works
NCMAG is clinically driven, which means cancer specialists from across Scotland can submit proposals for treatments that they believe will provide benefits to cancer patients. By giving ‘Once for Scotland’ advice, NCMAG aims to minimise duplication of work across the country and reduce variation in access. The NCMAG team provides the necessary expertise to undertake full clinical and health economic review and is made up of health services researchers, pharmacists and a health economist supported by a project management team. The team use their expertise to find and review all available clinical and health economic data associated with the proposed use. This means that the quality of the review is more robust than local processes are able to offer.
NCMAG works with key stakeholders including patient groups and public partners. The NCMAG council, which makes the decisions, is made up of experts, including medical and pharmacy specialists in cancer care, a cancer service manager finance and public partners, which ensures there are appropriate levels of expertise in the decision making process. This provides assurances that the decisions we make take into account both clinical and cost-effectiveness issues alongside the voices of patient groups.
Positive outcomes for patients with cancer
NCMAG opened for business on 1 April 2022. The NCMAG council meets quarterly, and the team can review two or three proposals each time. The first council review of a proposal took place in June 2022, and a total of five decisions were made in 2022, four of which were positive. This is great news for cancer patients in Scotland.
One of the latest decisions the council have made is particularly noteworthy it is abiraterone plus prednisolone as a new treatment option for patients with high risk early prostate cancer. The patent for abiraterone expired during 2022 meaning more cost-effective generic alternatives have become available, so its use in this indication is both off-label and off-patent. Abiraterone has been shown to both delay progression and improve overall survival in this patient group, giving patients with prostate cancer a new treatment option which is simple to take in a tablet form and will give them valuable extra time with family and friends.
Future work of the NCMAG
Looking to the future, the team are working closely with the Scottish Cancer Network as they develop National Clinical Management pathways and identify more off-label treatments that clinicians would like to be included as treatment options for patients.
We’ve also have had some initial discussions with the University of Strathclyde to explore research opportunities and consider how we can evaluate the impact of medicines made available through the NCMAG process.
We have four deadlines in 2023 for new proposals and have already received four proposals, so I think we will continue to be busy throughout 2023 and beyond. Two of the proposals are new treatment options for mesothelioma patients, which is something I am personally happy to see.
During my long career in cancer care, I’ve seen massive improvements in the medicines we can deliver and also the way we can do it. There is currently a national drive and enthusiasm to try and do more things ’Once for Scotland’ for cancer care and the work of NCMAG plays an important part in this. It’s a privilege doing this – working in cancer care gives you a reassurance that what you are doing brings improvements for cancer patients.
Heather Dalrymple is the National Clinical Lead for Cancer Medicines at Healthcare Improvement Scotland.
For more information on the work of NCMAG, visit the Healthcare Improvement Scotland website.