Health Economics
Poor Adherence to Oral Cancer Drugs a Growing Concern By Wayne Kuznar Chicago, IL—The number of oral oncolytic drugs has increased dramatically, but despite increased convenience, there is growing concern regarding adherence, said Winson Y. Cheung, MD, MPH, Assistant Professor, University of British Columbia Division of Medical Oncology, Vancouver, at a session on adherence at ASCO 2013. “Oral drugs shift the onus of treatment adherence from healthcare providers to patients,” Dr Cheung said. Cancers at more tumor sites are being treated with oral therapy, and the duration of therapy is lengthening. Adherence is an issue not only with antineoplastic drugs but also with nononcology drugs, he said. In one study of 169 patients with chronic myelogenous leukemia (CML), only 14% were 100% adherent to a daily regimen of imatinib (Gleevec) over a 3-month period. Although 91% of the prescribed doses were taken, 71% of the patients took less than the dose prescribed, and 15% took more. Suboptimal responses were more likely in patients with a higher mean percentage of missed doses. Treatment response is related to adherence, noted Dawn L. Hershman, MD, MS, Associate Professor of Medicine and Epidemiology, Columbia University Medical Center, New York. In chronic-phase CML, nonadherence to imatinib adversely affected event-free survival: the 5-year event-free survival rates were 76.7% in adherent patients and 59.8% in nonadherent patients. Predictors of Nonadherence Predictors of treatment discontinu-
ation or nonadherence have been identified. Among women with earlystage breast cancer, those aged <40 years had the highest risk of discontinuation of endocrine therapy. Age ≥65 years and the presence of comorbidities were other factors associated
“Asking patients about adherence detects 50% of nonadherence.” —Dawn L. Hershman, MD, MS with increased rates of discontinuation. Approximately 33% of women with early-stage breast cancer discontinued aromatase inhibitor therapy within 2 years because of an adverse effect; the rate of discontinuation because of musculoskeletal symptoms was 24.3%. Higher prescription copayments also predict nonpersistence with aromatase inhibitor therapy. Focusing on patients at the highest risk of discontinuation is an effective use of resources, Dr Hershman said. Other factors that predict cancer drug discontinuation are being single, being nonwhite, and therapy not being administered by an oncologist, said Dr Hershman. Strategies to Improve Adherence Improving adherence requires a multifaceted approach that relies on several strategies: • Patients should be encouraged to call with questions about their regimen • The regimen should be as simple as possible
• The consequences of missing doses should be explained to the patient. Involving family members and significant others can aid adherence. Simply “asking patients about adherence detects 50% of nonadherence,” she said. Technology may be a helpful resource for improving adherence. Phone consultation and daily text messaging reminders increased adherence to imatinib from 79.3% to 98.2% in a study of patients with chronic-phase CML. Texting reminders twice a week for 3 years also reduced the rate of discontinuation of anastrozole (Arimidex).
“There is evidence to suggest that the reduction of out-of-pocket expenses improves medication adherence across clinical conditions….Reducing copayments can potentially improve adherence for large numbers of geographically diverse patients.” —Winson Y. Cheung, MD, MPH Dedicated nurse managers assigned to patients at high risk for nonadherence, as well as collaborative care models are other potential solutions, said Dr Cheung. Pharmacist-led interventions are also effective, especially in the setting of polypharmacy. “There is evidence to suggest that the reduction of out-of-pocket expenses improves medication adherence
across clinical conditions,” Dr Cheung said. “Compared with other effective interventions that are relatively complex and resource intensive, reducing copayments can potentially improve adherence for large numbers of geographically diverse patients.” “Overadherence” “Overadherence” is an emerging concern in oncology, because patients sometimes believe that “more is better.” It is often overlooked, because most research has focused on underadherence, but the transition to oral oncolytics requires attention from providers and researchers to this new phenomenon. Pharmacy Channel Matters In a retrospective cohort analysis, Michael E. Stokes, MPH, of United BioSource Corporation, Montreal, Quebec, and colleagues found that patients with cancer whose prescriptions were provided by the specialty pharmacy were more likely to be adherent to their oral oncolytic agents than patients who filled their prescriptions through the traditional retail channel. Among 46,521 patients identified from claims databases who were prescribed either oral erlotinib (Tarceva), imatinib, or capecitabine (Xeloda), the rates of discontinuation of the initial prescription were higher among patients who filled prescriptions at traditional retail compared with those who received their medications via the specialty pharmacy for all 3 agents examined (erlotinib, 2.3% vs 0.1%; imatinib, 1.6% vs 0.1%; capecitabine, 1.9% vs 0.3%; P <.001 for all). n
Two Surveys Confirm Drug Shortages Are a Persistent Problem, Increasing Costs By Caroline Helwick Chicago, IL—Recent surveys of hematologists/oncologists show that drug shortages persist, that oncologists are adapting in ways that often raise the cost of cancer care, and that most oncologists have no guidance to aid their decision-making. A survey of 250 physicians showed that 83% of physicians encountered shortages of curative and palliative chemotherapy agents between March and September 2012. Many physicians reported that shortages affected the quali-
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ty and cost of patient care, because physicians were forced to substitute more expensive drugs for cheaper generics. “Drug shortages are affecting the treatment of curable malignancies. We don’t know the extent to which adaptations forced by these shortages led to adverse clinical outcomes for patients,” said Keerthi Gogineni, MD, MSHP, Medical Oncologist, Abramson Cancer Center, University of Pennsylvania, Philadelphia, at ASCO 2013. Shortages have also interfered with
American health & drug benefits
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patient participation in clinical trials, Dr Gogineni added. “We were surprised by the large number of oncologists who had to make changes in how they care for patients due to drug shortages,” she said. “Unfortunately, cancer drug shortages are likely to persist, but doctors are adapting to this new reality as best they can. We need more uniform guidance to ensure that the modifications in treatment are being made in the most educated and ethical way.”
The survey was distributed to 455 US oncologists and hematologists; 250 members responded, and 214 surveys were analyzed. Approximately 66% of respondents practiced in community-based private settings, and 33% practiced in academic settings. The data reflect drug shortage experiences from March 2012 to March 2013. Shortages were most frequently reported for leucovorin, liposomal doxorubicin, 5-fluorouracil (5-FU), bleomycin, and cytarabine.
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