Access and adherence to long-term cancer therapies are emerging as major public health issues around the world, as high out-of-pocket costs for oral oncolytics are linked to nonadherence that can directly affect patient outcomes, said Dawn L. Hershman, MD, MS, Professor of Medicine and Epidemiology, Columbia University Medical Center, New York, NY, at ASCO 2016.
“Solutions should involve increasing access and reducing cost, especially out-of-pocket costs. In addition, there may be options with intensified pharmacy efforts that can identify barriers to access quickly,” she said.
Adherence rates among patients with chronic diseases, such as cancer, in developed countries average only 50%, according to Dr Hershman. The rate is even lower in developing countries.
“We need to think globally about this issue. The striking impact of poor adherence is going to have an even greater magnitude where resources are scarce, leading to inequities in access to healthcare,” she said.
Cost Affects Adherence
Despite the efficacy of hormone therapy in breast cancer, many women discontinue their medication or take it intermittently over the course of their treatment. In her 2010 study of more than 8000 women with breast cancer, approximately 25% of patients discontinued their hormone therapy, and 25% were taking their medications >80% of the time.1
“Only about half of patients were taking the right amount of medication for the full duration of their treatment,” said Dr Hershman. “This has clinical implications; stopping therapy early for hormonal therapy impacts survival.”
Although nonadherence often stems from toxicity, cost is also a modifiable risk. The cost of all oral medications has increased dramatically, from an estimated $40 billion in 1999 to approximately $234 billion in 2008, said Dr Hershman, and the cost of new oral agents now exceeds $10,000 monthly.
“While use has not changed since 2006, spending on oral oncologics available in the US market has risen dramatically. Wth the increase in approvals for oral medication, both of these are going to increase substantially,” she said. In addition, insurance coverage and lack of patient access also drive adherence.
A previous study of women with early-stage breast cancer showed an association between copayment and adherence to hormone therapy, with patients aged >65 years the most affected.2 For a 90-day supply of medication, copays of >$30 monthly resulted in a substantial decrease in adherence, she noted.
Her new study showed that adherence was best in patients with household net worth >$750,000 versus those with low (<$250,000) or medium ($250,000-$750,000) net worth.3
“The amount that patients are spending on these drugs is increasing on a yearly basis. In patients with CML [chronic myeloid leukemia], for example, copay requirements have risen substantially over time, along with the increased cost of tyrosine kinase inhibitors,” she said.
Reducing Costs Can Improve Outcomes
By estimating the costs of patient nonadherence and of treating metastatic cancer, a 2013 study showed that full coverage for hormonal therapy was cost-saving.4
“Compared with the current Medicare Part D Prescription Drug Benefit, eliminating patient cost-sharing for aromatase inhibitors would improve health outcomes and save money. The incremental cost of coverage for aromatase inhibitors could be offset by the cost reductions from cancer recurrences averted,” Dr Hershman said.
With an average cost reduction of approximately $275 per beneficiary, society would save almost $17 million annually for the approximately 60,000 patients who receive breast cancer therapies.4
Reducing the cost of drugs may be an economic imperative, but it must be done in a way that does not compromise innovation, she added.
The Cancer Drug Coverage Parity Act of 2015 is one solution. “This legislation would require health insurance plans that cover traditional chemotherapy to provide equally favorable coverage for orally administered, anticancer medications,” Dr Hershman said.
Another solution may be to modify the cost-sharing requirements of the Part D benefit design so that Medicare beneficiaries only pay 50% of their coinsurance until their out-of-pocket costs reach $4700 instead of 100% of coinsurance.
Although promising, these mechanisms are not currently in place. “Ultimately, policy level efforts are needed to address these complex barriers to quality healthcare,” Dr Hershman concluded.
- Hershman DL, Kushi LH, Shao T, et al. Early discontinuation and nonadherence to adjuvant hormonal therapy in a cohort of 8,769 early-stage breast cancer patients. J Clin Oncol. 2010;28:4120-4128.
- Neugut AI, Subar M, Wilde ET, et al. Association between prescription co-payment amount and compliance with adjuvant hormonal therapy in women with early-stage breast cancer. J Clin Oncol. 2011;29:2534-2542.
- Hershman DL, Tsui J, Wright JD, et al. Household net worth, racial disparities, and hormonal therapy adherence among women with early-stage breast cancer. J Clin Oncol. 2015;33:1053-1059.
- Ito K, Elkin E, Blinder V, et al. Cost-effectiveness of full coverage of aromatase inhibitors for Medicare beneficiaries with early breast cancer. Cancer. 2013;119:2494-2502.