Availability and Access to Orphan Drugs for Rare Cancers in Bulgaria: Analysis of Delays and Public Expenditures

Abstract

Rare cancers are defined by an annual incidence of fewer than 6 per 100,000. Bearing similarities to rare diseases, they are associated with substantial health inequalities due to diagnostic complexity and delayed access to innovative therapies. This situation is further aggravated in Southeastern European countries like Bulgaria, where limited public resources and expertise underscore the need for additional policy and translational research on rare cancers. This study aimed to explore the availability and access to orphan drugs for rare cancers in Bulgaria for the period of 2020-2023. We cross-compared data from both the European Union and national public sources to evaluate the number of available and accessible orphan drugs for rare cancers, the delay from market authorization to reimbursement, the dynamics of public expenditures, and regional disparities in access across the country. We juxtaposed the main characteristics of oncological and non-oncological orphan drugs as well. Only 15 out of 50 oncological orphan drugs that were authorized by the European Medicine Agency were accessible for rare cancer patients in Bulgaria. The median delay between market authorization and inclusion in the Bulgarian Positive Drug List was 760 days. The total expenditures for all orphan drugs for rare cancers amounted to EUR 74,353,493 from 2020 to 2023. The budgetary impact of this group rose from 0.24% to 3.77% of total public medicinal product expenditures for the study period. Rare cancer patients represent a vulnerable population that often faces limited to no access to treatment. We call for targeted European and national policies to address this major inequality.

Keywords: Bulgaria; cancer costs; health inequalities; orphan drugs; rare cancers.

Figure 1

(A) Number of OD cancer drugs authorized by the EMA and their accessibility in Bulgarian PDL; (B) external delay between EMA authorization and inclusion in the PDL; (C) internal delay between PDL inclusion and first NHIF expenditure; (D) total delay between EMA authorization and first NHIF expenditure.

Figure 2

(A) Total cancer OD expenditures (July 2020–September 2023); (B) total expenditures per cancer OD; (C) difference between the total costs for orphan and non-orphan cancer drugs; (D) ratio between orphan and non-orphan cancer drug expenditures per patient (July 2020–September 2023).

Figure 3

(A) Cancer ODs and number of hospital providers per region; (B) number of regions and hospital providers per cancer OD drug; (C) proportion (in %) of all non-orphan cancer drug expenditures per region; (D) proportion (in %) of all cancer OD expenditures per region.

Figure 4

Market share of each company among orphan and non-orphan cancer drug products.