Medical Tourism for Rich Chinese

choi

It is 8:30 pm, Tuesday, May 30. The cn.nytimes,com has not translated it.

Sui-Lee Wee, Life-or-Death Medical Tourism; Wealthy Chinese look abroad for critical care to avoid their overburderned health system. New York Times, May 30, 2017.
https://www.nytimes.com/2017/05/ ... urism-hospital.html

Excerpt in the window of print: Better care, but challenges upon return

Note:
(a) Guo Shushi's (Sing Tao Daily: 郭树实) stomach cancer (medical term: gastric cancer) "roared back even after Mr Guo, a 63-year-old real estate developer, endured surgery, chemotherapy and radiation at two hospitals [in China]. * ** Mr Guo was at the Dana-Farber Cancer Institute in Boston, receiving a new immunotherapy drug, Keytruda, which is not available in China. In April, nearly four months later, his tumor has shrunk and his weight has gone up. * * * The cost: about $220,000 — all paid out of pocket [because Mr Guo does not have health insurance]."

Regarding Keytruda, a Merck trademark for pembrolizumab (a monoclonal antibody against PD-1). The latest development first.
(i) The drug is so new, there are few medical reports on its effectiveness -- certainly not on gastric cancer.

Press release: Data for KEYTRUDA® (pembrolizumab) Across 16 Types of Cancer from Merck's Industry-Leading Immuno-Oncology Program to Be Presented at the 2017 ASCO Annual Meeting. Merck, May 17, 2017
http://investors.merck.com/news/ ... eeting/default.aspx
(Merck "today announced that new and updated data from studies of KEYTRUDA® (pembrolizumab), the company’s anti-PD-1 therapy, will be presented at the 53rd Annual Meeting of the American Society of Clinical Oncology (ASCO) in Chicago, June 2 – 6, 2017. At this year’s meeting, researchers will present data from more than 50 abstracts investigating the use of KEYTRUDA as monotherapy and in novel combinations across 16 cancers, including non-small cell lung cancer (NSCLC), melanoma, urothelial carcinoma, microsatellite instability-high (MSI-H) cancers, gastric cancer and breast cancer. Additional longer-term progression-free survival (PFS) and overall survival (OS) data for KEYTRUDA in monotherapy and as a combination therapy in first-line NSCLC from KEYNOTE-024 and KEYNOTE-021G will be presented")
(A) progression-free survival (PFS)
NCI Dictionary of Cancer Terms (NCI stands for US National Cancer Institute), undated.
https://www.cancer.gov/publicati ... r-terms?cdrid=44782
(B) https://www.cancer.gov/publicati ... =overall%20survival
(2 results found: overall survival and overall survival rate)
(ii) On Sept 4, 2014, US Food and Drug Administration (FDA) approved its use to treat advanced melanoma (there were detailed indications that I will not go into). (On Dec 22, 2014 FDA approved a similar monoclonal antibody nivolumab (Opdivo; Bristol-Myers Squibb) to treat the same.)
(iii) So far, FDA has approved Keytruda, alone or in combination with other drug(s), to treat melanoma, non-small cell lung cancer (NSCLC), head and neck squamous cell carcinoma (HNSCC), Hodgkin lymphoma, urothelial carcinoma, microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) solid tumors or colorectal cancer, See

Keytruda Is Now Approved in 9 Indications.
https://www.keytruda.com/hcp/
(A) Take notice Gastric cancer is not one of them. In other words, FDA has not approved Keytruda treat gastric cancer. That is why, Aetna in a policy statement says Keytruda's use in gastric cancer patients is experimental, see Pembrolizumab (Keytruda)
www.aetna.com/cpb/medical/data/800_899/0890.html
("Aetna considers pembrolizumab (Keytruda) experimental and investigational for all other indications including the following (not an all-inclusive list):" gastric cancer among others (such as breast cancer) )
, and the cost will not be covered -- even for its policy holders in US.
(B) Indeed Merck on May 23, 2017 (a week ago) has a press release titled "FDA Grants Priority Review to Merck's Supplemental Biologics License Application (sBLA) for KEYTRUDA® (pembrolizumab) for Treatment of Recurrent or Advanced Gastric or Gastroesophageal Junction Adenocarcinoma."
(C) The only medical report I can find of Keytruda in treating gastric cancer is

Muro K et al, Pembrolizumab for Patients with PD-L1-Positive Advanced Gastric Cancer (KEYNOTE-012): a multicentre, open-label, phase 1b trial. The Lancet, 17: 717-726 (June 2016)
thelancet.com/journals/lanonc/article/PIIS1470-2045(16)00175-3/fulltext
("all [39] responses were partial. All 39 patients were included in the safety analyses")

This is a phase 1 clinical trial to assess whether a new drug is toxic to patients, not its effectiveness (which would be addressed in phases 2 and 3), Besides, patients got "partial" improvement, meaning the cancer might shrink but not vanish.

The clinical trial was called KEYNOTE-12, much like law enforcement or the military use "Operation so-and-so."
(iv) Even for treatment of a FDA-approved cancer (NSCLC), improvement in patients is statistically significant, but only measured by months.

Reck M et al, Pembrolizumab versus Chemotherapy for PD-L1–Positive Non–Small-Cell Lung Cancer. New England Journal of Medicine, 375: 1823-1833 (November 2016)
http://www.nejm.org/doi/full/10. ... =featured_home&
("Median progression-free survival was 10.3 months * * * in the pembrolizumab group versus 6.0 months * * * in the chemotherapy group [conventional treatment as the control] * * * The estimated rate of overall survival at 6 months was 80.2% in the pembrolizumab group versus 72.4% in the chemotherapy group")

choi

(e) "A total of about 4.3 million cancer cases were diagnosed in China in 2015, or almost 12,000 cases a day, compared with 2.4 million in 2010, according to the state-run news media. The five-year survival rate of Chinese cancer patients is around 30 percent, compared with about 70 percent in the United States, according to China's National Cancer Prevention and Research Center. * * * In March, the authorities in Beijing said that they would bar public hospitals from imposing consultation fees [or called 'registration fees' 挂号费 (consultation fee: singular for ONE hospital) ] on patients, in a bid to reduce public discontent.

The first sentence does not necessarily mean cancers have become more common in China. The cause could be more patients seeing more competent doctors or improved diagnosis.

(f)
(i) "Oscar ZHOU 周继昭, who founded Ryavo Health Management [(Shanghai) Co, Ltd 瑞弗健康管理（上海）有限公司; 2013- ] of Shanghai, another medical travel agency"
(ii) "Cai Qiang 蔡强— the founder of Beijing Saint Lucia Hospital Management Consulting Company [Pty, Ltd 北京盛诺一冢医院管理有限公司; 2011- ], in which the Silicon Valley venture capital firm Sequoia Capital has invested an undisclosed amount * * * Mr Cai, who is widely considered the pioneer of medical travel in China * * *  Cai said he started the company after being moved by the friendliness of Australia's doctors and nurses when his daughter was born."

proprietary company
https://en.wikipedia.org/wiki/Proprietary_company
(a form of privately held company in Australia and South Africa that is either limited or unlimited; Under Australian law, a proprietary limited company (abbreviated as 'Pty Ltd'))

(g) "Last November, Zhao Xiaoqing, 31, a bridge designer in the Chinese city of Nanjing, took her 5-year-old daughter, Kefei, to the Essen University Hospital in Germany to get proton therapy treatment for her child’s brain tumor. The treatment is available in Shanghai only for children 14 and above. She spent about $140,000, more than half of that borrowed from relatives.  Kefei's tumor shrank. Ms Zhao, who went to Germany with Ryavo Healthcare, is a satisfied customer"
(i) City of Essen is in the most populous state of Germany: North Rhine-Westphalia (capital: Düsseldorf). At the very end of 2015, populations of Essen and Düsseldorf are 583,000 and 612,000, respectively.
(ii) Company. In About Us. Essen University Hospital, undated.
https://www.uk-essen.de/en/unternehmen/
("This year, Essen University Hospital is celebrating a very special anniversary-100 years. Back in 1909, it took up its operation as the 'Städtische Krankenanstalt' with only four clinics. Since then, the Hospital has continuously evolved, becoming a teaching hospital in 1963. * * * [motto:] First-Rate Medical Services - Because We Care")
(A) The "company" refers to the hospital.  The URL alludes to the German name of the hospital: Universitätsklinikum Essen.
(B) German-English dictionary
* Universitätsklinikum (noun neuter) or Universitätsklinik (noun feminine): "university hospital"
   ^ Klinik (noun feminine): "clinic"
(iii) University of Duisburg-Essen
http://uaruhr.org/page/university_of_duisburg_essen/
("Few people know that Duisburg is one of the oldest university towns in Germany. Duisburg’s first university was officially opened in 1655, but was dissolved in 1818 in favor of the newly founded university in Bonn. Now the Universität Duisburg-Essen is Germany’s youngest university, through the merger of Universität Duisburg and Universität Essen in 2003. The university is situated in the central and western part of the Ruhr area and both campuses were founded in 1972. About 31,000 students are now enrolled in eleven departments. A research staff of 3,000 academics and non-academics fuel this university")

Duisburg is west of Essen, whose borders are separated by about 5 miles. Düsseldorf is on the southern border of Duisburg.
(iv) Medulloblastoma. National Center for Biotechnology Information, undated
https://www.ncbi.nlm.nih.gov/pubmed/19841429
("is the most common malignant brain tumor in children. Patients with medulloblastoma are stratified into ''standard'' and ''high'' risk categories based on age at diagnosis, degree of surgical resection, and disease spread. In children older than 3 years of age, the long-term survival can be achieved in approximately 85% of standard risk patients and 70% of high risk patients with a combination of chemotherapy and irradiation. Younger children, particularly infants, are at a significantly higher risk of side-effects of treatment")

choi

(b) "Chinese people took an estimated 500,000 outbound medical trips last year, a fivefold increase from a year earlier, according to Ctrip.com International, a Chinese travel booking company, which offers medical travel on its website. While the bulk of that is focused on plastic surgery and routine examinations, medical travel agencies say the number of critically ill Chinese patients leaving the country for medical treatment is growing.  'China is among the countries where we have seen the greatest growth in recent years,' Dr Stephanie L Hines, the chairwoman of executive health and international medicine at the Mayo Clinic, said in an email."

Executive Health Program. Mayo Clinic, undated
www.mayoclinic.org/departments-c ... erview/ovc-20253196
caters to "executives."
(c) "Mr Guo is one of more than 1,000 patients that one company based in Beijing, Hope Noah Health Company, says it helped last year [mostly to US or Japan]— a number it says was double that of the year before."

Hope Noah Health Company  厚朴方舟出国看病服务机构
http://www.hopenoah.com/en/

Remove the "en" in the URL, and you will reach the Chinese-language website.
(d) "As recently as the 1970s, China's health care system provided cradle-to-grave medical support. But despite a huge health care reform plan, its public hospitals are overburdened, with too few beds and doctors to deliver the kind of care that many in the West take for granted. A 2015 study by The Lancet based on United Nations criteria found that China ranked 92 out of 188 countries, after Cuba and Mexico."

The NYT report helpfully supplies the link:
GBD 2015 SDG Collaborators, Measuring the Health-Related Sustainable Development Goals in 188 Countries: A Baseline Analysis from the Global Burden of Disease Study 2015. The Lancet, 388: 1813-1850 (Oct 8, 2016).
http://thelancet.com/journals/lancet/article/PIIS0140-6736(16)31467-2/fulltext
(Figs 1-3:  Iceland (ranking No 1; score: 85), Singapore (2)>> Ireland (No 13; 81)> Germany (No 15; score: 80)>> Israel (No 23; score 77)> Japan (No 27; score: 76)> US (No 28, score: 75)> Taiwan (province of China) (No 32; score 74)> South Korea (No 35; score: 73) >> Cuba (No 66; score: 65)>Mexico (No 69; score: 64)> Palestine (No 76; score: 62)>>China (No 92; score: 60) )
(i) The acronyms in the authorship are spelled out in the title.
(ii) Hong Kong was not included.