Oral Chemotherapy: Benefits and Costs

Did you know some patients with cancer can receive their chemotherapy in the form of pills taken at home? It’s true! Oral chemotherapy is prescribed in many cases and it has some advantages over traditionally administered chemo, but it can also have barriers and challenges. In the paragraphs below, Oncology Nurse Navigator, Melisa Williams, RN, OCN, ONN-CG, shares some insights and expertise gained by working with patients treated using oral chemotherapy.

Chemotherapy, the use of medicines or drugs to treat cancer, has been around since the 1940s. Chemotherapy is most commonly cytotoxic, meaning the medicine kills cancer cells, and it is administered to patients through an IV (intravenously). In recent decades, chemotherapy has become available in oral forms (pills patients can take by mouth).

Cancer Treatments Evolve: Oral Chemotherapy

Cancer research breakthroughs and the accessibility of specific mutational and genetic testing make this a very exciting time in the evolution of cancer treatments. Discoveries about human cellular biology and cancer’s responses to different treatment types improve and expand our knowledge. These things directly affect the availability of more cancer treatment options for patients.  The amount of new information that becomes available every day about cancer subtypes and effective treatments is encouraging. These new findings challenge oncology providers to remain flexible and modify their practices as they rely on the ever-changing evidence-based standards of care. 

Benefits of Chemo Pills vs. IV

There are many advantages for patients to receive chemo treatment in the form of pills versus IV if the option is available. For example, it is often more convenient to manage the oral meds from the comfort of home rather than traveling back and forth to an infusion center for IV chemotherapy. The attractiveness of these benefits depends on patients’ circumstances. It may be more important to use oral chemo options when treating patients for whom transportation is an issue or who have mobility challenges.

The convenience of oral chemo can also benefit patients who are full-time caregivers themselves. For these patients frequently going to an infusion center for chemotherapy is too disruptive to their other obligations. Patients continuing to work through their course of therapy may have to take less time off if they don’t have to physically go to an office for treatment. The obvious contrast is that patients who use oral chemo do not have to get as many needle sticks as those receiving chemo by IV  and potentially avoid the need for a port. 

These benefits sound like most people would want to explore the option, but there are challenges to treatment with oral chemotherapy as well. 

Access Challenges

Once your physician prescribes this medication, there are several steps in the process that may seem daunting. The first barrier is how to actually get the medicine. These medications cannot typically be obtained from retail pharmacies. Rather they come from specialty pharmacies that mail the order to the patient’s home.

A big issue that affects patients’ access to oral chemo can be affordability.  The high cost of many of these pills relates to the intricate and lengthy research involved in their development and FDA approval.  This is especially true of medications specific to individual mutations. These therapies are made for very specific use and don’t have as broad an application that would allow companies to recover the research costs by distributing it over a high volume of orders. Therefore, the fewer “prescriptions” they fill for that therapy, the higher the share of cost that is passed along.

But what about patients with insurance? Doesn’t that take care of the cost?

Insurance Coverage

The cost of oral chemo can also be affected by reimbursement systems. A patient’s insurance, that covers IV chemotherapy as a medical benefit may consider and cover oral chemotherapy as a part of a patient’s drug plan.  Typically, insurance drug coverage plans are not as financially helpful as the medical part of health plans. This difference can mean a patient would have to pay a higher portion of the cost of treatment for oral rather than IV chemotherapy.

A recent article from Kaiser Health News (KHN.org) reports that oral chemotherapy agents are typically placed in the most expensive price tier in insurance formularies and Medicare part D plans.  Out-of-pocket costs for these treatments can reach 35% of the total cost. This level of co-pay or co-insurance can add up quickly.

Medicare Patients

Individual’s insurance coverage will vary as will the cost of their portion. For patients with Medicare, there are some coverage nuances. Most oral treatments are paid under the Medicare Part D, which is Medicare’s drug supplement plan. However, there are some chemo pills that can be covered under Medicare Part B.  These are typically pills that also have an IV version of the same drug available. 

The fact is, most people find the affordability of oral chemo a barrier to access.  Until the entire system – healthcare insurance, pharmaceutical companies, and political/Government committees make changes in how we cover costs of care, patients have to find other solutions.

Helpful Tips:

There are some common ways to overcome these obstacles and finding the answers to these questions may be a helpful place to begin. Patients should learn:

• Is this medication available as a generic?
• Are there co-pay programs available through the drug company or through disease funds or charitable organizations?
  • If so, what is the application process?
  • Does this application process expire after a certain amount of time and need to be resubmitted?
• Does the drug manufacturer have a website with financial guidance, co-pay cards, rebate cards, etc.?
• Does my insurance work with a specific specialty pharmacy?
• Does my specialty pharmacy offer financial counseling?
• Does my cancer center have assistance programs available to help with costs?

An Excellent Resource

As an Oncology Nurse Navigator, I frequently help patients find ways to overcome these barriers and challenges. I work closely with Social Services, pharmacies, and drug manufacturers to find financial assistance for obtaining specific medications.  This is a small part of the medication navigation process.  This assistance is sometimes available through the manufacturer.  Sometimes there are grants specific to certain diseases that are available for those meeting the criteria. 

All of these programs vary, based on the drug.  Most often an application process is required to determine whether a patient qualifies for assistance.  Some programs are strictly for uninsured or under-insured patients.  Other programs are helpful with high co-pays for commercial or Medicare-insured patients.

A cancer diagnosis is stressful enough, without having to worry about the financial cost of treatment. Oral chemo can be an excellent option for many patients if they can access it.  It is good to know help is available through many different channels. My goal as a patient’s Oncology Nurse Navigator is to help make this process as smooth as possible for my patients.

What to read next?

To learn more about Thompson Cancer Survival Center’s group of Oncology Nurse Navigators, follow the link to read Nurse Navigators: Expertise Confirmed.

To read about other cancer-fighting medications and Thompson Cancer’s Oncology Pharmacy, read 5 Ways Oncology Pharmacists Keep You Safe

To better understand the impact nutrition can have on patients’ outcomes, read The Link Between Nutrition & Healing

Visit the website thompsoncancer.com  or News & Blog | Thompson Cancer Survival Center and explore other topics.