Cost of drugs to control cancer-associated symptoms may add to patient financial toxicity
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The high cost of certain drugs to control cancer-associated symptoms can lead to substantial financial toxicity, according to results of a cross-sectional, descriptive study published in JCO Oncology Practice.
The findings, which also revealed wide variations in the costs of drugs to manage seven cancer-related symptoms or conditions, highlight the need for discussions on cost-effective management strategies and to promote less expensive options, according to researchers.
“Symptom-control drugs can be expensive, and a simple, well-intentioned, seemingly harmless prescription can cause great economic burden to patients,” Arjun Gupta, MD, assistant professor of medicine in the division of hematology, oncology and transplantation at University of Minnesota Medical School, told Healio.
Spending on symptom control can contribute substantially to financial toxicity, given the number and frequency of drugs used by patients with cancer, Gupta said.
“For example, let us consider anorexia/cachexia,” he said. “No drugs are FDA-approved for it, and ASCO guidelines suggest it is reasonable to not prescribe a drug for it. We found that out-of-pocket costs for just a 2-week supply of medications for anorexia/cachexia ranged from $5 (generic olanzapine or mirtazapine tablets) to $1,156 (brand-name dronabinol solution). Clinicians should be aware that costs of the same drug can vary substantially between different formulations.”
Gupta and colleagues pursued the research because such costs are “typically ignored,” he said, and although cheaper alternatives may be available, clinicians may be unaware of the costs.
In addition to anorexia and cachexia, the study focused on drugs used to manage chemotherapy-induced peripheral neuropathy, constipation, diarrhea, exocrine pancreatic insufficiency, cancer-associated fatigue and chemotherapy-induced nausea and vomiting. The researchers selected the symptoms based on their pervasiveness, impact on quality of life and availability to be managed by several drugs. They only included drugs focused on symptom palliation and not drugs unavailable in the United States.
Gupta and colleagues identified retail price (cash price at retail pharmacies) and lowest price (discounted, best-case scenario of out-of-pocket costs) for patients without insurance for a typical fill of each drug formulation by using the GoodRx website. To minimize geographic and temporal variation, as well as stay consistent with pricing information in ASCO guidelines and prior methodology on cancer drug pricing, researchers collected data for a single ZIP code (10065, Upper East Side, Manhattan) for a single month (May 2021).
Results showed wide-ranging lowest prices for patients using a coupon:
- For anorexia and cachexia, costs ranged from $5 for generic olanzapine or mirtazapine to $1,156 for brand-name dronabinol. Prices also varied greatly by formulation of the same drug or dosage. For 5 mg olanzapine, costs ranged from $5 (generic tablet) to $239 (brand-name orally disintegrating tablet).
- For peripheral neuropathy, the gap between generic and brand-name duloxetine was $12 to $529.
- For constipation, newer agents such as methylnaltrexone cost as much as $1,001 compared with less than $15 for sennosides or polyethylene glycol.
- For fatigue, generic dexamethasone or dexmethylphenidate cost $15 vs. $1,284 for brand-name modafinil.
- For nausea and vomiting, costs of a four-drug prophylaxis regimen ranged from $181 to $1,430.
Depending on whether a clinician writes a prescription for an ondansetron tablet, an ondansetron oral-dissolving tablet, a brand-name tablet, a brand-name oral-disintegrating tablet or a brand-name oral biofilm, Gupta said costs can vary vastly.
“As an example, the out-of-pocket cost for 15 units of 4 mg of generic metoclopramide is $3 for tablets and $60 for oral-disintegrating tablets,” he said.
“When more than one suitable option is available to manage a symptom, clinicians can consider prescribing less expensive formulations,” he continued. “Clinicians should reevaluate the risk-benefit ratio of each prescription they write, no matter how simple, especially in the context of the limited data to support the use of some of these symptom-control drugs.”
Gupta added that the financial toxicity that arises as a result of the varied pricing in the drugs is not necessarily anyone’s fault, as physicians are “well-intentioned” and “busy ... making dozens of decisions in an hour.” The onus, he said, is on the larger health care system to make sure patients receive both proper care and less costly alternatives to brand-name drugs.
“It is the job of the system to make it easy to do the right thing,” Gupta said. “Health systems must promote clinician-pharmacist partnerships and electronic medical record-embedded real-time benefit tools to implement these data.”
To continue their research, Gupta and colleagues are investigating the cumulative burden of such spending over the course of a patient’s cancer experience, keying in on costs beyond primary cancer care procedures like chemotherapy, scans, clinician visits and hospitalizations.
“For example, a patient with pancreatic cancer may pay several hundred, if not thousands, of dollars a month for medications such as pancreatic enzymes and insulin, and medications to improve pain, nausea and appetite,” Gupta said.
For more information:
Arjun Gupta, MD, can be reached at Division of Hematology, Oncology & Transplantation, University of Minnesota, 516 Delaware St. SE, MMC 480, PWB 14-100, Minneapolis, MN 55455; email: arjgupta@umn.edu.
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