Discarded Targeted Oral Anticancer Medication—A Hard Pill to Swallow?

Abstract

Oral targeted agents for cancer are among the most expensive outpatient prescription drugs dispensed in the US. 1 These drugs, often distributed as specialty drugs, can cost more than $170 000 per patient per year. 2 Patients in the US pay a greater share of their health care costs than patients living in other developed countries. As a result, terms such as "financial burden," "financial hardship," and "financial toxicity" have risen, especially in the US, to describe the untenable phenomenon patients, particularly those treated for cancer, face: treatment can result in long-term financial hardship 3 that may be so severe as to result in medical bankruptcy 4,5 or inability to complete recommended treatment protocols. 6 Moreover, the cost of targeted oral medications for cancer treatment continues to rise. One study 7 using Surveillance, Epidemiology, and End Results (SEER)-Medicare data reported that oral prescription drugs for leukemia increased by 27% between 2007 and 2013, reaching $2.35 billion. Another study 8 analyzing the SEER-Medicare 5% Cancer File showed that mean 30-day total spending on targeted oral anticancer drugs more than doubled in 5 years, from $4011 in 2011 to $8857 in 2016.Federal, state, and private health insurance plans alongside patients pay for oral anticancer drugs. Drugs that are purchased but discarded can represent a substantial cost given the high price of oral anticancer drugs. For payers, the cost associated with discarded targeted oral agents depends on a combination of the cost of the drug and the total number of refills, whereas for patients the cost of discarded drugs varies by the insurance design of their pharmacy benefit, specifically the copayment or coinsurance for a prescription, and limits on annual out-of-pocket payments, if any. 9 In absence of a prescription drug insurance plan, patients may cover the full costs of all prescriptions filled. A change in dose or medication, disease progression, or patient noncompliance, which may be driven by financial reasons, can result in discarded drugs. Reasons for discarded drugs are beyond the patient's and insurer's control, such as medications dispensed in a quantity or dosage that is not easily adjusted through multiples of the initially prescribed dosage.In this issue, Lam et al 10 estimated the cost of oral anticancer drugs discarded owing to dose modification or discontinuation. The authors narrowed the top 50 best-selling pharmaceuticals from drugdiscoverytrends.com to 22 oral anticancer drugs. Using data from published clinical trials associated with the drugs, the investigators applied wholesale drug prices and multiplied by the percentages of patients who required dose reduction or discontinued the drug altogether. Reasonable assumptions were made about the number of remaining unused pills. They estimated that the median cost associated with discarded pills was $1751 with a range of $43 to $27 200-the high upper bound attributable to a drug with a high cost and multiple dose reductions at Opinion