"Day-to-day worry:" NEPA providers grapple with ongoing cancer drug shortage

Aug. 6—Dr. Lisa Thomas never dealt with a drug shortage so acute she had to make difficult decisions about patients' chemotherapy — until last week.

That's when Hematology and Oncology Associates of Northeastern Pennsylvania ran out of carboplatin, a vital chemotherapy drug used to treat breast, bladder, lung and other cancers. It's one of numerous cancer treatments in scarce supply amid an ongoing drug shortage that has affected patients and providers across the country for months.

The Dunmore practice exhausted its carboplatin Tuesday and was without the drug until a minimal shipment arrived Thursday afternoon. That's enough to cover current patients this week, but not enough for new patients.

"It's a day-to-day worry right now," said Thomas, a medical oncologist/hematologist there. "We just don't want patients worrying about more than they need to. They have enough on their plate."

Even a brief unavailability of carboplatin forced Hematology and Oncology Associates to adjust some treatments and delay others.

"We're making every effort not to have to omit the drug ... and this isn't meant to sound cavalier, but, you know, it's kind of like anything, you have to look at the list, you have to talk to the doctors, you have to know which patients have curable malignancies and they have to get the treatment first," Thomas said. "They're the ones that really need to stick to the schedules."

A late May survey by the National Comprehensive Cancer Network (NCCN) found that 93% of surveyed cancer centers were experiencing a carboplatin shortage while 70% reported a shortage of cisplatin, another vital chemotherapy. At the time, only 64% of those centers were able to treat all patients receiving a carboplatin-containing regimen according to the intended dose and schedule.

"This is an unacceptable situation," NCCN CEO Dr. Robert W. Carlson said in a June news release. "We are hearing from oncologists and pharmacists across the country who have to scramble to find appropriate alternatives for treating their patients with cancer right now."

Faced this past winter with a shortage of injectable 5-fluorouracil, an intravenous treatment for gastrointestinal and other cancers, Geisinger Health pivoted to the alternative oral drug capecitabine. Doctors described it as an equivalent and equally effective treatment, but capecitabine's dosing and side-effect profile differs from fluorouracil's and substituting one for the other affects patient scheduling and the logistics of cancer care.

While a relatively small number of Geisinger patients were directly affected by that switch, officials said ongoing drug shortages add unwelcomed uncertainty for patients and providers alike.

"It has been an extremely challenging time and it injects unneeded stress and uncertainty into already difficult conversations with patients and families about cancer and cancer treatment," Geisinger Cancer Institute Chair Dr. Rajiv Panikkar said late last month. "The assurance that I want to give is that our teams are working extremely hard to make sure every patient gets the best possible treatment, but it is taxing us in ways that we're not familiar with."

The NCCN survey showed 26% of respondents reported shortages of 5-fluorouracil in late May. The American Society of Health-System Pharmacists (ASHP), which tracks drug shortages, listed several fluorouracil injection products that remained in short supply as of July 27.

ASHP's shortage database also includes docetaxel products, one of the drugs used to treat Edwardsville artist and photographer Amy Bezek's breast cancer. Now cancer free, Bezek completed chemotherapy infusion treatments at Fox Chase Cancer Center in Philadelphia early last year, followed by radiation treatments locally.

"Chemo kicked my butt in, and if I was going through that now with the shortage of medicine, you're already so stressed just being diagnosed with cancer," the 48-year-old said. "Especially chemo, it's just weird, I would sleep for weeks. My bones hurt so bad I couldn't even explain the pain. It was horrible. So, to go through that now and have that added stress on top of everything already, I couldn't even imagine."

The monthslong, ongoing drug shortage also makes Bezek more anxious about the already distressing prospect of cancer potentially reemerging.

"I'm super spiritual and I trust the universe ... but it's hard sometimes," she said. "You literally can just sit in your house and cry not knowing."

Benjamin Andrick, Geisinger assistant director of hematology/oncology pharmacy, said the system has collaborated and communicated to mitigate the impact of cancer drug shortages since January. Those efforts have been effective, he said, acknowledging some triaging occurred to ensure patients most in need had access to necessary treatments.

"But that's only for a limited number of medications," Andrick said early last month. "Most patients' care has been uninterrupted."

While the majority of Geisinger's cancer patients receive their chemotherapy at infusion centers, Andrick noted oral chemotherapy has become more prevalent amid the ongoing drug shortages. But some of those treatments, including capecitabine tablets, have also been in short supply.

"And I think that's a great example of how this drug shortage is just so vast," Andrick said. "It's impacting not only the infusion-clinic side, which is where most people get their care, but it also impacts oral chemotherapy."

Commonwealth Health System said in a recent statement that the majority of chemotherapy treatments are administered in outpatient clinics, physician's offices or at home.

"The oncologists on the medical staff at our hospitals are predominantly independent providers that administer chemotherapy in their private practices," Commonwealth's statement notes. "As a result, we have a very limited number of patients receiving chemotherapy in our hospital-based infusion centers and have been able to meet their needs."

NCCN, of Plymouth Meeting, is calling on the federal government, drug makers, care providers and the insurance industry to do their part to mitigate current shortages and prevent future scarcity.

The government and its agencies must assure a regulatory environment that secures a steady supply of safe and effective cancer treatments, according to the group. The pharmaceutical industry has an "ethical and moral obligation" to assure such a supply, while insurance companies and other payers must put patients first and ensure coverage for alternative cancer treatments, NCCN said in a statement.

Cancer drug shortages are a market-based issue and don't have to be inevitable, NCCN Senior Director of Policy and Advocacy Alyssa Schatz said in a recent interview.

"Paradoxically, low drug prices are actually a key driver of this shortage," Schatz said. "We hear all the time about how the U.S. overpays for drugs and that conversation is related to brand-name drugs, but, when we're talking about shortages, it's most often happening in the generic space."

Generic drug manufacturers operate on a razor-thin margin, which can lead to quality and supply issues, she said.

"I think looking at economic solutions to support a high quality and a safe generics market is important," Schatz said.

She noted NCCN's commitment to work with all stakeholders to develop comprehensive solutions to the drug shortage challenge. She also encouraged patients affected by shortages to contact policymakers, members of Congress and others capable of causing change.

"Patients should know that their voice matters," she said. "I work with policymakers regularly and there is nothing more likely to catalyze change than a powerful patient story."

Contact the writer: jhorvath@timesshamrock.com; 570-348-9141; @jhorvathTT on Twitter.

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