Aromatase inhibitors the most common type of
hormone therapy were found to be less expensive than their brand name
counterparts and increased breast cancer treatment adherence by 50 percent,
finds study published in Journal of the National Cancer Institute.
suggest that more effort should be made to reduce out-of-pocket costs for these
potentially life-saving medications. This is especially important given the
rapid increase of expensive oral cancer therapies," said study leader Dawn L.
Hershman, MD, MS, associate professor of medicine at the College of Physicians
and Surgeons, and associate professor of epidemiology at the Mailman School of
Public Health, Columbia University Medical Center. Dr. Hershman is also leader
of the Breast Cancer Program at the Herbert Irving Comprehensive Cancer Center
at NewYork-Presbyterian/Columbia University Medical Center.
"We know that hormone therapy for women with
hormone receptor-positive breast cancer can reduce recurrence by up to 50
percent," added Dr. Hershman. "However, work by our group and others has shown
that a substantial number of women discontinue treatment before the recommended
five years or do not take the prescribed dose. This is increasingly important
because we are starting to learn that even longer therapy—up to 10 years—may be
beneficial. It's critical that we understand why people do not take their
medication and what we can do to improve adherence."
In a previous study, Dr. Hershman and her
colleagues found that higher co-payments for
aromatase inhibitors (AIs) significantly
decreased adherence to therapy. "When AIs were released in generic form in
2010, we had a unique opportunity to study whether a reduction in overall
medication cost would make a difference in adherence," she said. To find out, the
researchers examined the pharmacy records of 5,511 women ages 50 or older with
early stage breast cancer (requiring lumpectomy or mastectomy) who were
prescribed hormonal therapy between 2007-2012. Each patient was followed for a
period of 24 months.
The researchers found that women taking generic
AIs were more 50 percent more likely to take the medications on schedule and
30% less likely to discontinue therapy early compared to women taking brand
name AIs. Among women on brand name generics, 33 percent discontinued therapy,
compared to just 16 percent on generics.
As monthly out-of-pocket co-payments increased,
adherence rates decreased. Even a small increase in monthly co-payments, from
less than $15 to $15 to $30, resulted in a significant decrease in adherence,"
said Dr. Hershman. "That might not seem like a lot money, but it can be a big
expense if you multiply it over five or ten years and you have other
prescriptions to pay for."
There are several factors that can contribute to
medication nonadherence. "Cost is not the only reason," said Dr. Hershman. "But
it can intensify other factors such as side effects. Up to 40 percent of women
taking AIs experience joint stiffness. If you add a high co-payment to the mix,
that's often enough to make them discontinue therapy."
Another reason for nonadherence, at least with
AIs, is that patients don't see day-to-day signs that the medications are
working. "In contrast, if you have hypertension and you're getting regular
blood pressure checks, you can see what happens when you stop taking your
medication," she said.
Dr. Hershman offered several suggestions for
increasing adherence to AIs. "First, it's important for physicians to ask
patients whether they are able to pay for their medications," she said. "Many
patients aren't comfortable raising this issue and will just discontinue
therapy. By engaging patients in conversation, we may be able to come up with a
solution, perhaps by finding less expensive alternatives or by asking
pharmaceutical companies to assist patients with co-payments."
Physicians also need to remind patients that AIs
are effective. "Every time a patient comes for a visit is an opportunity to
reinforce the importance of adhering to treatment," Dr. Hershman said.
Finally, states could pass bills requiring health
insurance companies to keep co-payments for oral cancer therapies at affordable
levels, a move that several legislatures are considering. "From a public policy
standpoint, we want to do everything possible to ensure that patients get life-saving
medications. We will save many more lives by treating early stage breast cancer
with hormonal therapy than by treating metastatic disease with chemotherapy."
Because of the growing availability of costly
oral biologic therapies for cancer, the problem of medication nonadherence is
likely to grow even larger. The average monthly cost of brand-name and generic
AIs are $380 and $150 respectively, while the average monthly cost of oral
biologics ranges from $5,000 to $8,000.
Medication nonadherence is a major issue
throughout the health care system, according to the researchers. One recent
study estimated that the annual cost of nonadherence to all types medications
is $289 billion, or 13 percent of total U.S. health expenditures.