Making sense of the dollars: Evaluation of financial toxicity in patients of breast medicine receiving oral chemotherapy at Roswell Park.
Authors: Liu Angel W. , Adesola Cherish , Matthews Conti Christina , Cypes Ilana , Hamad Lamya , Babcock Ashley , Steinig Lynda 
Published: June 2023

e18519

Background: Increasing costs of oral chemotherapy have become a significant barrier to cancer care with the potential to cause treatment abandonment and noncompliance. The primary objective of this study is to evaluate the financial toxicity of oral chemotherapy in the Breast Medicine Service at Roswell Park Comprehensive Cancer Center (RPCCC). Methods: This was a retrospective chart review of patients at RPCCC who were diagnosed with breast cancer and prescribed oral chemotherapy between 8/1/21 - 7/31/22. The primary outcome evaluated was average out-of-pocket (OOP) cost of an oral chemotherapy prescription. Secondary outcomes studied included 1) the number of patients enrolled in manufacturer patient assistance programs (PAPs), copay cards, foundation grants, and/or New York State Elderly Pharmaceutical Insurance Coverage (EPIC) program, and 2) median days to treatment start date, approval of prior authorization (PA) and/or PAPs. For patients who filled at outside pharmacies, days to first insurance claim were collected and compared to days to first fill for patients who filled at Roswell Park Pharmacy. Results: A total of 116 patients with a median age of 64 and 122 oral chemotherapy prescriptions were included. Majority of the patients were white (n = 93; 80%) and enrolled in Medicare managed plans (n = 58; 50%). Palbociclib (n = 47; 39%) and capecitabine (n = 29; 24%) were most commonly prescribed. 49 patients filled at Roswell Park Pharmacy; average OOP cost was $48.00 (range: 0-2239.50) per prescription claim. Average OOP cost was $85.18 for patients with Medicare managed plans, $23.35 for patients with commercial insurance, and $3.66 for patients with government-funded insurance. Twenty patients (17%) enrolled in PAPs, foundation grants, copay cards, and/or EPIC program. OOP costs prior to any financial assistance was available for thirteen patients; median OOP cost was $2491.51 (403.62-18165.94). Median days to approval of PAPs and approval of PA was 10 (1-50) and 0 (0-14), respectively. When filling internally at Roswell Park Pharmacy, median days to treatment start date was 6 (0-61) compared to 9 (0-67) for those who filled at outside pharmacies. There was a significant difference (p = 0.0111) between the median days to first fill for patients who filled at Roswell Park Pharmacy (0 days [0-25]) and the median time to first insurance claim (2 days [0-20]) for patients filling at outside pharmacies. Conclusions: Despite utilization of financial assistance program, OOP costs remain high for cancer patients. Having a defined workflow to screen and identify patients at risk for financial toxicity and the ability to refer to appropriate resources to mitigate OOP costs promptly is vital to prevent delays in treatment. Utilizing an integrated health-system specialty pharmacy can be helpful to streamline patient access and avoid further treatment delays.