A box of erlotinib 100mg tablets, also known by its brand name Tarceva, a cancer treatment drug ... [+]
There’s good news on the cancer front. In the U.S., the cancer death rate dropped by 2.2% from 2016 to 2017, which is the largest yearly decrease ever recorded. Lower rates of lung and skin cancer deaths appear to be the biggest drivers. It’s unclear how much of the decrease can be attributed to factors such as recent advances in cancer treatments, early detection, or improved lifestyle habits like smoking cessation. But, it’s probable that at least some of the progress can be attributed to better cancer treatments.
Nevertheless, a vexing and persistent problem in U.S. healthcare is inequality in access to treatments of all kinds, including cancer therapies.
For example, disparities in lung cancer treatment may point to an access problem. Less than 62% of lung cancer patients in the U.S. receive treatments recommended by the National Comprehensive Cancer Network (NCCN) guidelines, according to research recently published in the Annals of the American Thoracic Society. About 22% percent got no treatment, and 16% received treatment that was less intensive than recommended.
The NCCN has established clinical guidelines for treating both non-small cell lung cancer and small cell lung cancer. Together, the two types of lung cancer are the leading causes of cancer deaths in the U.S.
In “Disparities in Receiving Guideline-Concordant Treatment for Lung Cancer in the U.S.” Dr. Erik Blom and colleagues report that the probability of receiving the guideline-recommended treatments is even lower than 62% for African American patients and the elderly.
The findings are based on a review of nearly 442,000 lung cancer cases diagnosed between 2010 and 2014 in the U.S. National Cancer Database.
The study did not examine reasons for the disparities cited. But, an educated guess suggests several possibilities. Some patients, especially elderly, may simply opt not to get treatment. Others, after a weighing of benefits and risks, may decide that on balance treatment is not worth it. But, for a subset of patients lack of access to healthcare is a probable reason.
For the purposes of this post the focus is prescription drugs. Access to prescription drugs is multi-dimensional, with both regulatory and reimbursement dimensions playing critical roles.
For most cancer drugs, the problem in the U.S. is not on the regulatory approval side. To illustrate, the U.S. approves more oncology drugs than Europe. And, for those approved in both U.S. and Europe the time to approval tends to be shorter in in the U.S.
But, regulatory approval is a necessary but insufficient condition for access. This is where insurance comes into play, as well as affordability. Insurers tend not to exclude cancer drugs from the formulary, or list of covered treatments. However, they often impose high rates of cost-sharing and other restrictions or conditions of reimbursement. Barriers to cancer care access can also include denials for coverage of diagnostics and mutational profiling using next-generation sequencing.
Despite co-payment assistance, and in a number of instances free prescription drug programs offered by pharmaceutical companies, some patients cannot afford the high cost of a targeted therapy. This includes the cost of medicines, hospital, and physician services.
Here, the type of insurance that a person has matters - commercial, Medicare, Medicaid - as the bulk of treatment costs are paid for by third parties. And, within each type of insurance differences in coverage can be significant. That is, formulary decisions and restrictions on coverage matter.
Consider Medicaid, for example. Medicaid is sometimes not accepted at certain cancer treatment centers. Likewise, physicians may elect not to take Medicaid patients. Nonetheless, it’s better to have Medicaid than no insurance. According to a 2019 analysis of electronic health records of over 30,000 patients, in states where Medicaid access was expanded under the Affordable Care Act, previous racial disparities in timely cancer treatment between African American and white patients virtually disappeared.
Summing up, disparities in lung cancer treatments exist. These differences may be partly attributed to inequality in (insurance) access to guideline-driven care.
