It’s not only cancer drugs that can lead to financial toxicity: commonly prescribed medications used to manage cancer-associated symptoms can put an additional economic burden on the patient.

Although financial toxicity in cancer care has been well-documented, with much attention focused on the high price tags associated with immunotherapy and other new drugs, little attention has been paid to drugs that are prescribed for symptom relief.

A new study focusing on the cost of this group of drugs was recently published in JCO Oncology Practice.

“These costs are typically ignored, since many of these drugs are typically available as generics and considered ‘cheap,’ and they are sometimes available over-the-counter, so clinicians may be unaware of their cost,” commented lead author Arjun Gupta, MD, an assistant professor of medicine, Division of Hematology, Oncology and Transplantation at the University of Minnesota Medical School, Minneapolis.

However, the cost of these drugs can mount up, especially if new-formulation brand name products are used.

“A simple, well-intentioned, seemingly harmless prescription can cause great economic burden to patients,” Gupta lamented.

“This is particularly critical considering that for some symptoms, data to support routine use of medications is lacking,” he said.

 As an example, Gupta points to anorexia/cachexia in patients with cancer.  “No drugs are FDA-approved for it, and ASCO guidelines suggest it is reasonable to not prescribe a drug for it,” he said.

And yet, the team found that drugs were being prescribed for this symptom, and that the cost varied widely. “We found that out-of-pocket costs for just a 2-week supply of medications for anorexia/cachexia ranged from $5 for generic olanzapine or mirtazapine tablets to $1156 for brand-name dronabinol solution,” he said.

There was also wide variation for the same drug, depending on whether or not it was a brand name product: for olanzapine, a generic 5 mg tablet cost only $5, but the same drug in a brand-name oral disintegrating tablet cost $239.

Another example is metoclopramide, which is often used to treat nausea and gastric stasis: which specific product is prescribed can make a big difference in the cost. “The out-of-pocket cost for 15 units of 4 mg of generic metoclopramide is $3 for tablets and $60 for oral disintegrating tablets,” Gupta told Medscape Medical News.

Wide Variations in Price

For their study, Gupta and colleagues analyzed costs for medications and formulations that are currently used to manage seven cancer-related symptoms: anorexia/cachexia, chemotherapy-induced peripheral neuropathy, constipation, diarrhea, exocrine pancreatic insufficiency, cancer-associated fatigue, and chemotherapy-induced nausea and vomiting.

The team assessed the average retail costs and the lowest available costs for patients who pay cash for these drugs. They used GoodRx, a nationally available drug price comparison website that provides real-time information on drug prices available to consumers at participating pharmacies in their zip code.

Their analyses showed that many of these agents were very expensive, and the point-of-sale prices were highly variable, both in comparisons within medications (formulations and by generic vs brand name) as well as when compared across different medications.

For example, for the relief of constipation, the cost of sennosides or polyethylene glycol was around $15 while newer agents such as methylnaltrexone were far more expensive ($1,001).

For cancer-associated fatigue, the cost of generic dexamethasone or dexmethylphenidate was $15 whereas brand-name modafinil was considerably higher at $1284.

“Clinicians should be aware that costs of the same drug can vary substantially between different formulations,” he said. “Whether the clinician writes for ondansetron tablet, or ondansetron oral dissolving tablet, or brand-name ondansetron tablet, or brand-name oral disintegrating tablet, or brand-name oral biofilm — this can vastly change costs for patients.”

He suggested that where there is more than one suitable option to manage a symptom, clinicians should consider prescribing less expensive formulations.

“Clinicians should reevaluate the risk–benefit ratio of each prescription they write for, no matter how simple, especially in the context of the limited data to support the use of some of these symptom control drugs,” Gupta said. “Ultimately, health systems must promote clinician–pharmacist partnerships and electronic medical record-embedded real-time benefit tools to implement these data.”

“We hope that our study can promote weighing the pros and cons of a prescription, taking financial burdens as a consideration,” he concluded.

Gupta and co-author Ramy Sedhom, MD, were supported by individual Conquer Cancer/the ASCO Foundation Young Investigator Awards. Co-author Helen Parsons, PhD, reports support from NIH P30 CA77598 Masonic Cancer Center and the Leukemia and Lymphoma society for unrelated work. Gupta has disclosed no relevant financial relationships.

JCO Oncology Practice. Published online September 24, 2021. Full text

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