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A few weeks ago, I had a discussion with Kris Ghosh, MD one of our local GYN Oncologists, (listen here). We talked specifically about Doxil, the usual second line treatment for recurrent ovarian cancer. We agreed that the lack of availability of the drug does limit options for these patients, with further increase in already heightened anxiety levels for patients and families. Add to the mix the increase in stress levels of oncologists and our staffs trying to handle one more insult to a broken healthcare system. In one patient who was due to start treatment I was able to substitute topotecan (Hycamptin). Fortunately, she is responding and tolerating the agent very well. We had put her name on our list of patients who were waiting for Doxil when it became available. So I was able to use the drug allocated to her for another patient with multiple myeloma. The only agent that had controlled his disease was Doxil. I guess the problem worked out well in these cases, but it appears that this shell game is going to become routine. The question arises: “Is this the harbinger of rationing cancer care?”
In my residency training in the late ‘60’s/early ‘70’s, I rotated through the Nephrology service when hemodialysis was relatively new. Just like today, demand for the procedure far outstripped supply. One of the factors taken into consideration in a negative way was anyone whose renal failure was due to diabetes. That’s a lot of people!! Obviously, we were very uncomfortable being put in that predicament. Hindsight personalized this for me since my maternal grandfather died of sepsis after amputation of one of his legs for diabetic gangrene, my father died of every complication of diabetes and was hemodialyzed for 2 ½ years before his death, and I have type I diabetes and am on an insulin pump but fortunately no signs of renal impairment, yet. I’m sure my father would never have been treated during my training years. I’m sure our cancer patients experience similar anxiety and fear when faced our current dilemma.
Causes of shortages are multifactorial. In Doxil’s case, the manufacturing plant in Alabama was struck by lightning during the tornado earlier this year. Hard to believe but that’s the story. Obviously an unpredictable Serious Adverse Event (SAE). However, most of the chemotherapy drugs in short supply are older agents, e.g., bleomycin, cisplatin, cytarabine, daunorubicin, doxorubicin, etoposide, leucovorin/levoleucovorin, mechlorethamine, thiotepa, and vincristine. Many are now off patent and therefore priced lower as generics; so not as profitable. In some cases manufacturing of the drug was stopped in anticipation of newer and, of course, more expensive replacements. One of the predictable side effects replacing old, cheaper drugs with newer, more expensive agents is pushback from payors who deny coverage/payment. We then get on the authorization-denial-authorization-denial merry go round many times leading to a teleconference with the medical director of the health plan. All this takes time and can delay treatment for quite a while, adversely effecting results. Especially when used with curative intent and when there are no good substitutes, this is unacceptable. Another complication is the emergence of a “gray market” where drugs from questionable sources pass through unknown hands to our offices at up to 10 times the usual price. In the ‘90’s we called this brown-bagging. Trying to keep inventory straight as to which drug from what source belonged to whom was an added challenge.
From the above, it is obvious that health care is big business. An invaluable source of health care information is, therefore, the Wall Street Journal. In last weekend’s edition I learned that “Roche Holding AG has stopped delivering its drugs for cancer and other diseases to some state-funded hospitals in Greece that haven’t paid their bills.” This policy may extend to Spain, Portugal and Italy. Patients had to purchase chemotherapy from private pharmacies and bring them back to hospitals for administration. In the US, we find ourselves in a similar situation in that we can’t afford to purchase some drugs for our patients. So drug shortages are a global issue involving different causes requiring different approaches directed to specific problems.
I found two articles helpful in defining the problem and proposing possible solutions:
- Link, M., et. al.: Drug Shortages Threaten Patient Health and Safety; HemOnc today, vol 12 no 15, August 10, 2011, pg 1, 10-12.
- Johnson, P.E.: Drug Shortages: Impact and Strategies; JNCCN, vol 9 no 8, August, 2011, pp 815-819.