High Cost Deters Patients From Imatinib Treatment

Roxanne Nelson

September 18, 2010

August 5, 2010 — An increasing number of oral chemotherapy agents are coming on the market, but high cost and nonadherence remain barriers to their use. In fact, patients using oral biologic agents might be more likely to ration or discontinue treatment when dealing with economic hardship than patients receiving intravenous therapy, note the authors of a letter published in the August 5 issue of the New England Journal of Medicine.

As an example, Robin K. Kelley, MD, and Alan P. Venook, MD, both from the University of California, San Francisco, highlight the situation of 3 patients with metastatic gastrointestinal stromal tumors who discontinued treatment with imatinib (Gleevec, Novartis) because of economic hardship. All 3 of these patients participated in the clinical trial leading to the approval of imatinib for the treatment of gastrointestinal stromal tumors. It is an "unfortunate irony" that they are now unable to afford to continue treatment, the authors note.

"Our objective is to raise awareness of the risk of medication nonadherence during economic hardship," they write.

Disparity in Cost Burden

As previously reported by Medscape Medical News, oral chemotherapeutic agents are becoming increasingly available, giving patients a convenient and noninvasive treatment option. However, these agents tend to come with a very high price tag, and both private and public insurance plans in the United States frequently require patients to cover a large portion of the cost of these agents.

Most plans cover oral chemotherapy under a prescription benefit, which tends to require higher copayments. Conversely, intravenous infusions are traditionally covered under a medical benefit, which tends to be more generous in its coverage.

This duality in coverage was never meant to interfere with life-saving treatment. "The original intention of copayments and coinsurance was to limit unnecessary and inappropriate unitization of drugs," said David L. Knowlton, MA, a board member of the HealthWell Foundation, a national nonprofit organization that provides financial assistance to underinsured patients with chronic or life-threatening illnesses.

"Unfortunately, the intent has shifted from utilization to cost," he told Medscape Medical News in a previous interview.

Disease Recurrence With Nonadherence

Drs. Kelley and Venook point out that patients with metastatic gastrointestinal stromal tumors previously had a life expectancy that was counted in months. With imatinib, the median survival for these individuals is approaching 5 years. The use of high-dose imatinib or other kinase inhibitors can restore control when tumors become resistant to other treatment, they note, but the cost of imatinib can exceed $4500 per month. That can be a prohibitive amount for some patients.

"Nonadherence to treatment occurs in about 30% of patients with chronic myelogenous leukemia or gastrointestinal stromal tumor," they write, and it might be influenced by economic factors.

In the first case the authors describe, the patient had a massive gastric gastrointestinal stromal tumor and began taking imatinib in 2001, which resulted in a durable response for the next 8 years. But in 2009, the patient discontinued treatment because of decreased earnings. Within the next 6 months, the patient began to experience pain, and scans showed that the tumor was growing.

The second patient was diagnosed with a pelvic gastrointestinal stromal tumor and peritoneal sarcomatosis, also in 2001. Treatment with imatinib resulted in a sustained complete response, but in 2007, personal circumstances caused the patient to switch insurers. Since the patient was self-employed, it was impossible to obtain new insurance because of the preexisting condition. Imatinib was discontinued, and within 3 years, the patient experienced a recurrence of symptomatic peritoneal tumors.

In the third case, the patient had a gastric gastrointestinal stromal tumor with hepatic metastases that responded well to imatinib, which was started in 2001. But after the patient's business failed in 2008, imatinib was discontinued. The tumor recurred the following year with hematemesis, necessitating emergency surgery.

The authors point out that although tumor progression might have eventually occurred in all 3 of these patients despite adherence to treatment, "their cases illustrate that economic factors can influence the decisions that patients with cancer make about their care."

In response to this risk, especially in an economic downturn, the authors explain that in their own practice, they have implemented measures to "reinforce the importance of medication adherence, to refer patients to social workers and financial counselors, and to provide information about pharmaceutical companies' patient-assistance programs.

N Engl J Med. 2010;363:596-598.

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