Mortality rates across many cancer types have been declining for years. Less clear are the reasons why and, in particular, the role that treatment drugs have played compared with improved diagnosis, better screening, and declining rates of risky behaviors, such as smoking.
A study published in JAMA earlier this year sheds some light on this question when it comes to breast cancer (Plevritis 2018). Researchers at Stanford ran simulation models that compared actual breast cancer mortality rates with what the rates would have been had trends in mortality continued.
Their model found that in the year 2000, the actual breast cancer mortality rate was 37% lower than what trends would have predicted. Moreover, the analysis found that 56% of the reduction was from treatment drugs and 44% from improved screening and early detection.
The results for 2012 were similar: a decline of 49% compared with the expected baseline, and 63% of that reduction was from treatment drugs.
This study may be limited to just one cancer type, and it considered only treatment and screening. Even so, the results help to validate that emerging drug therapies have played an important role in bending the survival curve in the right direction.
Within days of publication of the JAMA study, a very different sort of study was published in the Journal of Clinical Oncology (Doshi 2018). This study analyzed 38,000 patients who had received a prescription for one of 38 oral cancer drugs in 2014 and 2015. The goal was to examine the relationship between patient out-of-pocket costs and “prescription abandonment”—failure to fill a new prescription within 90 days after it was adjudicated by the insurer. Patients in this study were covered by commercial and public payers. The connection between prescription abandonment and high cost has been studied before, particularly in specialty drugs. But would oncology be different?
The research team, led by Jalpa Doshi at the University of Pennsylvania, found that prescription abandonment rose with increasing cost share. For patients with a cost share of $10 or less, the proportion of patients who abandoned their prescription was 10%. When cost sharing reached between $100 and $500, the abandonment rate soared to 32%. And when cost sharing was higher than $2,000, almost half of patients abandoned their prescriptions. Even for a condition as serious as cancer, financial limitations prove to be a daunting barrier.
Source: Doshi JA et al., Journal of Clinical Oncology, Dec. 20, 2017
As different as the JAMA and Journal of Clinical Oncology studies are, viewed together they raise a troubling question: Will the progress we have seen in cancer survival rates plateau or even reverse if so many patients aren’t getting their prescriptions filled?
Benefit surveys indicate that high-deductible plans remain popular with employers while patients’ out-of-pocket costs continue to rise. Other protections against high health care costs are getting cast aside, leaving patients more and more exposed to costs. Copay assistance programs are a mainstay, although they are not available to patients covered by Medicare and Medicaid. New PBM aggregator programs that prevent copay assistance from contributing to the patient out-of-pocket maximum may increase patient costs by varying degrees. Although foundation support is available for patients, recent actions from federal investigations may call into question how these entities function in the future. And the 340B program may undergo significant changes that could affect services that some safety net hospitals offer to patients with limited financial resources.
Health care stakeholders can take steps to mitigate the effects of higher patient costs so that cancer outcomes continue to move in the right direction. They can embrace value-based care arrangements that encourage the utilization of treatments that deliver the best outcomes for the money spent. Drugmakers need to focus on how a drug improves total patient health, not just some carefully selected endpoints. They also need to factor in cost and health resource utilization. For their part, payers can develop processes that encourage the use of high-value therapies while avoiding insurmountable financial expense. Cancer outcomes are slowly but surely moving in the right direction.
Doshi JA, Li P, Huo H, et al. Association of patient out-of-pocket costs with prescription abandonment and delay in fills of novel oral anticancer agents. J Clin Oncol. 2018;36(5):z476–z482.
Plevritis SK, Munoz D, Kurian AW, et al. Association of screening and treatment with breast cancer mortality by molecular subtype in US women, 2000–2012. JAMA. 2018;319(2):154–164.