Out-of-Pocket Costs and Drug Shortages: Wade Iams, MD, MSCI

Patient out-of-pocket costs are among the most important and hardest-to-track costs in oncology, and insurance does not shield patients from substantial financial burden, according to Wade Iams, MD, MSCI, of Tennessee Oncology.

In an interview with The American Journal of Managed Care^®, Iams discussed out-of-pocket costs, generic chemotherapy shortages, and the infrastructure needed to deliver chimeric antigen receptor (CAR) T-cell therapy and bispecific T-cell engager (BiTE) therapy.

Health systems generally know what they pay for a drug and what they are reimbursed for the services around it, Iams said. What patients owe is much harder to see. "Insured patients can still have substantial out-of-pocket costs," Iams said.

Iams pointed to statistics showing that two-thirds of patients who declare bankruptcy because of health care costs are insured. "We're not good enough at tracking and helping alleviate the issue," Iams said.

What Platinum Shortages Revealed

Iams also described the strain of recent shortages of generic chemotherapy drugs. Cisplatin and carboplatin are foundational treatments for both non–small cell and small cell lung cancer, and Tennessee Oncology treats many patients with these cancers. When those drugs were scarce, the practice had to turn to oxaliplatin, a related platinum agent.

Although the drugs sound similar, Iams said, they are not interchangeable. Oxaliplatin can cause permanent nerve damage much more often than cisplatin or carboplatin.

"There can be major differences in toxicity," Iams said. The experience, he added, has made the practice more attuned to generic drug supply and to building the infrastructure and processes needed to get these drugs to patients.

What Limits CAR T and BiTE Access

Iams grouped immune-based treatments into 2 categories. CAR T-cell therapy requires weeks of manufacturing because a patient's immune cells must be collected and engineered into therapeutic cells. BiTE therapies are off the shelf and can be started within a week, with nothing extracted from the patient.

Both approaches push the immune system to fight cancer, and a strong immune response can bring fevers that look like infection, as well as confusion. The 2 main reactions are cytokine release syndrome and immune effector cell–associated neurotoxicity syndrome, Iams said.

Antidote infusions exist for these reactions, but Iams said access to the antidote when it is needed is the main limit on broader rollout across the country. Even a delay of several hours can change a patient's course, from an emergency department visit and brief hospital stay to a prolonged intensive care unit stay. In rare cases, the reactions have been fatal.

Subcutaneous (sub-Q) formulations may help. Injecting a drug under the skin rather than into a vein brings drug levels up to a lower peak and keeps them there longer, rather than producing a spike, and sub-Q versions have shown lower rates of these immune reactions.

"We're hoping that the sub-Q formulations will open more doors for safety for those compounds that have shown great ability to help control cancer," Iams said.