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Column: Ask The Pharmacist

Trends in cancer treatment

By Dr. Bob Anderson

Nearly all of us have been touched personally by a loved one or a close friend who is or has gone through cancer treatments. In most cases, treatment includes more than one drug, sometimes an infusion given at the oncologist’s office and, often, repeated in cycles until remission or adverse side effects appear. More patients now are being treated at home with potent oral anti-cancer drugs.

Most of the drugs available to treat cancer today have been on the market only for the past 10-15 years. I admit that of the 50 or so oral “chemo” drugs on the market today, I am familiar with only 20 percent of them—and I have not been retired that long! Many are biotechnology drugs, which specifically target and kill cancer cells; the older drugs were relatively indiscriminate in killing both cancer and normal cells, hence causing more side effects. These new discoveries and treatment improvements, however, come at a high cost.

Medical vs. pharmacy benefit

In the “old days,” if you were diagnosed with a cancer, it may have been treated with an infusion in the doctor’s office; this infusion was considered a part of your medical benefit (like Medicare Part B) and often came with a low copayment and administration fee. With more potent oral drugs on the market, the cost of outpatient drugs is considered a pharmacy benefit (like Medicare Part D).

In essence, the cost of treatment has been shifted to the consumer. Many policies require a 50 percent copayment, often resulting in an out-of-pocket cost in the range of $2,000 to $3,000 per month. Is it any wonder 50 percent of cancer patients do not adhere to prescribed medication due to cost? Studies have demonstrated if copayments are greater than $500, 25 percent of patients will not fill their prescription; another 6 percent will not fill it if the copayment is over $100.

Legislation

Federal legislation has increased access to care but not affordability. Many states, including Georgia, have passed an Oncology Parity Law to address the discrepancy between consumer costs of intravenous drugs in the office and oral chemo drugs at the pharmacy. But guess what? Medicare patients under federal insurance programs are excluded from the state laws! In addition, Medicare patients are not eligible for any coupons or discounts due to federal anti-kickback statutes. And a vast majority of cancer patients are over the age of 65.

So we have complex and toxic (4 percent of patients die from the drugs rather than the cancer) drugs that few can afford with no “money-back” guarantee if the drugs are ineffective or not tolerated. Instead of oncologists prescribing the treatment regimen of choice for a specific cancer, they must select what insurance plans will cover and what copayments their patients can afford. The result may be a reduction in both the quantity and quality of life.

Specialty pharmacies

Many of these expensive oral chemo drugs cannot be dispensed at a local community pharmacy. The main reasons are the high inventory cost as well as low and delayed reimbursements from insurance plans. To be honest, many pharmacists do not have the time or training with these new drugs to adequately counsel patients on their proper use and to monitor for side effects. Mail order (from who knows where) is not the answer either, as many such drugs have been found to be counterfeit.

Many insurance plans require or prefer the dispensing of these drugs from a specialty mail order pharmacy. These pharmacies are like Kentucky Fried Chicken—they only do one thing (dispense cancer drugs) and they do it (or at least try to do it) right. These pharmacies have trained pharmacists and nurses on staff to coordinate care at discharge from the hospital, educate patients and monitor adherence to therapy and for side effects. They are more aware of eligibility for financial assistance programs, if needed, and have a “direct line” to the prescriber with feedback on drug interactions or adverse effects.

Hope may be on the horizon: President Trump is concerned with the high cost of drugs, so perhaps a federal Oncology Parity Law will be enacted in the near future to help cover the cost of drugs for Medicare patients. Also in the pipeline over the next five to 10 years are generic biotech drugs—called biosimilars—which may be fast-tracked through the FDA review process despite opposition from the pharmaceutical industry.

Getting a cancer is bad enough; going bankrupt trying to treat it is just plain wrong.

Dr. Anderson is a professor emeritus from Mercer University, a sometime pharmacist at Northside Pharmacy in Jasper and a full-time resident of Big Canoe.

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