Because the economics and practice of this type of cancer care haven't yet caught up, relying on cancer drugs can cause problems for both patients and physicians.
While most insurance companies pay fully or partially for chemotherapy injections in a physician's office or cancer center, many plans don't cover much of the cost of oral cancer treatments. That often leaves patients with a bill that can total thousands of dollars a month.
And it creates a couple of problems for physicians. For one, patient compliance tends to go down when drugs are self-administered. Studies have found noncompliance rates as high as 43% in breast cancer patients treated with oral cancer drugs, for instance. And economic or insurance woes can compound the problem if patients worry about the drug costs and attempt to stretch out their supply.
Physicians' bottom lines can also take a hit. Medical oncologists often purchase infusion drugs wholesale and make money off the reimbursement for administering them in-office, but with oral pills they receive no direct payments.
"The orals trend is one that we're watching very closely," says Craig Comish, executive director for cancer services at Carolinas Medical Center, a 457-bed medical center in Charlotte. "Patients can be out large amounts of money for oral meds, and then the oral meds are not coming through physician offices so the management of care of the patients under the oral meds is sometimes a little fragmented."
There are some strategies for hospitals and physicians seeing an impact from the switch to oral cancer drugs. Some physicians are adding on retail pharmacies, which make filling prescriptions more convenient for the patient but also add an ancillary revenue stream that recaptures some of the money lost in drug sales. And when it comes to compliance, cancer centers can work with pharmacists, physicians, and other providers to monitor patients' pill supplies and educate them about the importance of adhering to the medication plans.
But for the most part, oral cancer drugs continue to be a disruptive innovation that the industry is still trying to wrap its head around.
A decade or so ago, intensity-modulated radiation therapy was considered cutting edge. The technology has since become fairly ubiquitous, and although it remains a useful procedure, the high cost of medical linear accelerators makes upgrades difficult and infrequent.
But new software developments are allowing some facilities to switch to what's known as volumetric arc therapy—a safer and more precise way to deliver treatment. RapidArc? radiotherapy technology, pioneered by Varian Medical Systems, cuts the dose rate significantly. Procedures that used to take 15-20 minutes can now be done in less than two minutes, says Richard Emery, executive director of the Trinitas Comprehensive Cancer Center, which was the first center in New Jersey to implement the new technology.
"The key to radiation oncology is precision and accuracy," he says. "If you can very carefully verify that the patient is in the exact right location prior to treatment, you want deliver treatment as quickly as possible can because over time we know that the patient can move."
As a bonus, the quicker turnaround time is a hit with both patients and physicians and makes for a decent marketing message.