Conditional approval of cancer drugs in Canada: accountability and impact on public funding

Short Communication

Conditional approval of cancer drugs in Canada: accountability and impact on public funding

S.K. Andersen, BSc MD*, N. Penner, A. Chambers, BSc MA, M.E. Trudeau, MA MD§,*, K.K.W. Chan, MD MSc PhD*,a, M.C. Cheung, MD SM*a




We examined how conditional market approval of cancer pharmaceuticals by Health Canada (hc) affects public funding recommendations by the pan-Canadian Oncology Review (pcodr). We were also interested to see how often hc conditions are enforced.


Health Canada and pcodr databases for 2010–2017 were analyzed for patterns in hc conditional authorization and post-authorization reviews of cancer drugs and for correlation with pcodr reimbursement recommendations.


Between 2010 and 2017, pcodr reviewed 105 unique drug–indication pairings; 21% (n = 22) had conditional hc authorization. In all cases, conditional authorization was given on the basis of preliminary data in a surrogate endpoint and was contingent on further data showing benefit in more robust outcome measures (for example, overall survival). Of those 22 drugs, 36% did not have updated data, 36% had updated data that met hc conditions, and 27% had data that met some, but not all, conditions. During the period considered, hc never revoked conditional authorization for failure to meet conditions. None of the 22 drugs was given an unconditional positive recommendation for public reimbursement by pcodr. A conditional recommendation was given to 11 of the drugs (50%), and reimbursement was not recommended for 6 drugs (27%) because of insufficient evidence.


One fifth of the cancer drugs reviewed for public reimbursement in Canada were conditionally authorized by hc based on preliminary data. Conditional authorization was associated with a recommendation against public funding by pcodr. No drugs had their conditional market authorization revoked for failure to meet conditions, suggesting that a more robust hc reappraisal framework is needed.

KEYWORDS: Medical oncology, health policy, health economics, Health Canada, pcodr


Few medical fields have seen as many therapeutic advances in recent years as oncology. As the development of new pharmaceuticals continues to accelerate, it falls to government regulatory bodies to adjudicate the treatments to approve and to health technology agencies to determine the treatments to recommend for public reimbursement. Regulatory and funding bodies operate under the dual tensions of providing expedient access to novel treatments for life-threatening conditions and of ensuring patient safety and equitable resource allocation1. Thus, critical review of the drug reimbursement and approval process is of great economic and social importance.

Drug approval in Canada is undertaken by Health Canada (hc) in a review process that accounts for safety and efficacy data from preclinical and clinical trials2. Successful drugs are issued a notice of compliance (noc) that authorizes the pharmaceutical company to market the drug. On occasion, hc instead issues a notice of compliance with conditions (noc/c), which stipulates that the developer will undertake further studies to confirm benefit; however, those stipulations are not legally binding and do not affect market access3. The process is analogous to the “accelerated approval” designation granted by the U.S. Food and Drug Administration4. In Canada, the noc/c policy gives earlier market access to drugs for “serious, life-threatening or severely debilitating diseases,” particularly when few treatments are available for such diseases or when the drug demonstrates potential for significant improvement over existing treatment options. Cancer drugs are frequently eligible for these expedited conditional authorizations. Upon review by hc, the noc/c conditions can subsequently be removed if early efficacy data are borne out in further trials5.

Once a cancer drug has obtained federal market authorization, each province must independently decide whether to provide public reimbursement for its use. In 2010, the pan-Canadian Oncology Drug Review (pcodr) was established by provincial ministries of health to assess cancer drugs and guide funding decisions6. The pcodr process is independent from the Common Drug Review, which assesses all other classes of medications7. The pcodr expert review committee (perc) evaluates clinical evidence, economic evidence, patient values, and adoption feasibility to generate a reimbursement recommendation that can then be used to guide provincial decision-making for all provinces except Quebec. The committee comprises medical oncologists, pharmacists, economists, an ethicist, and patient representatives6. The final perc decision can be to recommend reimbursement, to deny reimbursement, or to consider reimbursement once certain conditions have been met. With assistance from pcodr, funding decisions can be made in a way that is transparent, expert-guided, and timely. In addition, pcodr acts to reduce duplication of the review process and improve standardization between provinces. In 2014, pcodr was incorporated into the Canadian Agency for Drugs and Technologies in Health8.

A noc/c issued by hc expedites the progress from market authorization to funding recommendation, which is appealing to patients, providers, and manufacturers. Moreover, pcodr is able to review drugs for funding in parallel with the hc process. However, prior studies of the noc/c approval process have raised concerns that efforts by hc to expedite access are not routinely followed by critical reappraisal or enforcement of listed conditions3,9.

Few studies to date have specifically addressed the noc/c approval process as it relates to oncology and pcodr decisions. Here, we sought to determine whether conditions set by hc affect reimbursement recommendations by pcodr, how often cancer drugs receive early market authorization under the noc/c policy, and what evidence guides decision-making by hc. We also examined how frequently conditions set by hc are subsequently fulfilled.


We used the pcodr database to find all drugs assessed from initiation of the program in 2010 to March 2017. The hc Notice of Compliance database ( was searched to determine which of those drugs had received a noc/c market authorization. Drugs with noc/c status were reviewed in detail to determine the terms of their conditional approval and whether, subsequently, the stated conditions were met and full noc status was granted. A literature review and a search of for all relevant drugs were performed to determine whether further studies to address the hc conditions were available. The final pcodr recommendations for noc/c drugs were further assessed, with particular attention to any correlation with hc conditions. In cases in which one drug was approved for multiple indications, each indication was treated separately.


Between January 2010 and March 2017, pcodr reviewed 105 cancer drugs for consideration of public reimbursement; 16.2% (n = 17) had previously been given noc/c market authorization by hc. Of those 17 drugs, 4 were given more than one noc/c for separate indications, for a total of 22 unique marketing indications (Figure 1). One submission was subsequently withdrawn from pcodr consideration.



FIGURE 1 Flow chart of the pan-Canadian Oncology Drug Review (pCODR) process. NOC = Notice of Compliance; NOC/c = Notice of Compliance with conditions.

In all cases, hc provided conditional market approval on the basis of promising preliminary data in a surrogate endpoint (such as objective response rate) or in a single-arm study, and post-authorization conditions warranted completion of additional studies—that is, phase II or III clinical trials—to demonstrate benefit in more robust outcome measures such as progression-free survival, overall survival, or quality of life. In some cases, additional safety data were also requested. For 36% of the 22 identified indications, no updated data (n = 8) were available; updated data that met the noc/c conditions were available for another 36% (n = 8), and updated data that did not fully meet conditions were available for the remaining 27% (n = 6). One drug (crizotinib) and one drug combination (dabrafenib–trametinib) had subsequently received full authorization from hc at the time of our analysis (Table I). During the period under consideration, hc never revoked conditional market authorization for failure to meet conditions (Table I).

TABLE I Cancer drugs that were reviewed by the pan-Canadian Oncology Drug Review while they had market authorization under a Notice of Compliance with conditions (NOC/c) issued by Health Canada


No drug with noc/c status was given an unconditional recommendation for public reimbursement by perc. Reimbursement recommendations were given for 11 indications (50%) conditional on improvement in cost-effectiveness, and as of March 2017, submissions for 4 indications (18%) were pending. A reimbursement recommendation was not given for 6 noc/c drugs (27%). In all 6 cases, perc indicated that the evidence was insufficient to conclude that significant benefit was derived compared with existing treatments. For 2 indications, toxicity was an additional concern, and the resultant harm was felt to outweigh the evidence of benefit. Of the 6 indications not recommended for public reimbursement, 3 were re-submitted by the manufacturer for pcodr review after release of further clinical trial data. Of those 3, 1—crizotinib—was subsequently given a conditional recommendation for funding as second-line treatment for ALK-positive advanced or metastatic non-small-cell lung cancer, subject to improvement in cost effectiveness. In all cases, the second pcodr review was triggered by the drug manufacturer and not perc (supplementary Table I). Figure 2 depicts the post-approval timeline for all drugs reviewed.



FIGURE 2 Health Canada (HC) market authorization of cancer drugs. pCODR = pan-Canadian Oncology Drug Review; NOC/c = Notice of Compliance with conditions.


Several observations about the cancer drug approval and funding process in Canada arise from this study. First, the noc/c policy permits manufacturers to obtain conditional market authorization for cancer treatments that have not yet demonstrated benefit in overall survival or progression-free survival, arguably the most meaningful clinical outcomes. For at least 6 indications, a noc/c was granted on the basis of single-arm studies lacking a comparison with a reasonable standard of care. Concerns about surrogate outcomes have been raised by many authors1013.

Second, although noc/c market authorization is conditional, no defined timeline has been attached to the conditions, and no mechanism is in place to trigger reappraisal by hc. As a consequence, manufacturers have little motivation to complete and report additional clinical trials9. The absence of rigorous post-authorization evaluation is not unique to Canada; Pease et al.11 recently demonstrated a similar paucity of post-authorization studies after approval by the Food and Drug Administration in the United States. Meanwhile, the number of drugs given accelerated approval by the Food and Drug Administration with limited evidence has increased, with downstream implications for funding bodies12,13. In contrast, the conditional marketing authorization process in the European Union contains explicit deadlines and requires an annual review and renewal contingent on the stipulated conditions being met3.

The pcodr process provides a second checkpoint and opportunity for critical appraisal. In the case of noc/c drugs, the perc is less likely to recommend drug reimbursement without evidence of meaningful benefit—generally, improvements in overall or progression-free survival. In all cases in which public reimbursement was recommended, those recommendations were conditional on reducing cost to acceptable societal willingness-to-pay thresholds. In the event that perc recommended against public funding, we note that pcodr reappraisals were triggered by manufacturer resubmissions. As a whole, then, Canadian drug review and funding mechanisms appear to be driven by the pharmaceutical industry. Of course, the decision to publicly fund treatments ultimately rests with individual provinces and territories. Further analysis of pcodr’s impact on drug pricing and provincial funding decisions would be of value, although review of the Common Drug Review process for non-cancer drugs suggests that between 60% and 96% of recommendations are adopted by provincial funding agencies7. In contrast, funding recommendations by the U.K. National Institute for Health and Clinical Excellence (the equivalent of the Common Drug Review) are legally binding14.

We recognize that hc, pcodr, and provincial funding bodies have different priorities: ensuring the safety of drugs and making them available in a timely fashion for patients who lack other options on the one hand, and ensuring equitable and rational resource allocation on the other. The burden of proof that that proponents of new treatments must meet is certainly an ongoing debate. It is in no one’s interest to fund and treat patients with drugs that provide negligible benefit in the real world. Ideally, then, the regulation and funding of drugs should be a process of continual critical reappraisal. The creation of review bodies such as pcodr is a positive step. However, we argue that stronger hc legislation is needed to ensure the safe and appropriate treatment of cancer patients with novel pharmaceuticals.


We have read and understood Current Oncology’s policy on disclosing conf licts of interest, and we declare the following interests: NP, AC, MET, KKWC, and MCC are members of the pan-Canadian Oncology Drug Review (pcodr) Expert Review Committee (perc), a committee that convenes under the auspices of the Canadian Agency for Drugs and Technologies in Health. The Canadian Agency for Drugs and Technologies in Health is an independent, not-for-profit organization established in 1989 by the federal, provincial, and territorial governments.


*Department of Medicine, University of Toronto, Toronto, ON,
pan-Canadian Oncology Drug Review, Canadian Agency for Drugs and Technologies in Health, Ottawa, ON,
Division of Hematology and Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON,
§Canadian Centre for Applied Research in Cancer Control, Toronto, ON.


1 Mailankody S, Prasad V. Five years of cancer drug approvals innovation, efficacy, and costs. JAMA Oncol 2015;1:539–40. [Erratum in: JAMA Oncol 2015;1:544]
cross-ref  pubmed  

2 Health Canada. How Drugs Are Reviewed in Canada [Web page]. Ottawa, ON: Health Canada; 2015. [Available at:; cited 15 May 2017]

3 Lexchin J. Notice of compliance with conditions: a policy in limbo. Healthc Policy 2007;2:114–22.
pubmed  pmc  

4 New drug, antibiotic, and biological drug product regulations; accelerated approval—fda. Final rule. Fed Regist 1992;57:58942–60.

5 Health Canada. Notice of Compliance with Conditions – NOC/c (Therapeutic Products) [Web page]. Ottawa, ON: Health Canada; 2007. [Available at:; cited 15 May 2017]

6 Canadian Agency for Drugs and Technologies in Health (cadth). About the pan-Canadian Oncology Drug Review (pCODR) [Web page]. Ottawa, ON: cadth; 2017. [Available at:; cited 15 May 2017]

7 Gamble JM, Weir DL, Johnson JA, Eurich DT. Analysis of drug coverage before and after the implementation of Canada’s Common Drug Review. CMAJ 2011;183:E1259–66.
cross-ref  pubmed  pmc  

8 Canadian Agency for Drugs and Technologies in Health (cadth). About CADTH [Web page]. Ottawa, ON: cadth; 2017. [Available at:; cited 15 May 2017]

9 Law MR. The characteristics and fulfillment of conditional prescription drug approvals in Canada. Health Policy 2014;116:154–61.
cross-ref  pubmed  

10 Lexchin J. Quality of evidence considered by Health Canada in granting full market authorization to new drugs with a conditional approval: a retrospective cohort study. BMJ Open 2018;8:e020377.

11 Pease AM, Krumholz HM, Downing NS, Aminawung JA, Shah ND, Ross JS. Postapproval studies of drugs initially approved by the fda on the basis of limited evidence: systematic review. BMJ 2017;357:j1680.
cross-ref  pubmed  pmc  

12 Kesselheim AS, Wang B, Franklin JM, Darrow JJ. Trends in utilization of fda expedited drug development and approval programs, 1987–2014: cohort study. BMJ 2015;351:h4633.

13 Gellad WF, Kesselheim AS. Accelerated approval and expensive drugs—a challenging combination. N Engl J Med 2017;376:2001–4.
cross-ref  pubmed  

14 Clement FM, Harris A, Li JJ, Yong K, Lee KM, Manns BJ. Using effectiveness and cost-effectiveness to make drug coverage decisions: a comparison of Britain, Australia, and Canada. JAMA 2009;302:1437–43.
cross-ref  pubmed  

Correspondence to: Matthew C. Cheung, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2031, Toronto, Ontario MN4 3M5. E-mail:

aThese authors contributed equally to the present work. ( Return to Text )

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Supplemental material available at ( Return to Text )

Current Oncology, VOLUME 26, NUMBER 1, FEBRUARY 2019

Copyright © 2019 Multimed Inc.
ISSN: 1198-0052 (Print) ISSN: 1718-7729 (Online)