“There is no doubt,” says medical oncologist Neeraj Agarwal, M.D., of the University of Utah’s Huntsman Cancer Institute, “that ADT alone is not sufficient” in treating early metastasis (metastatic hormone-sensitive prostate cancer, or mHSPC). “It works so much better when it is combined” with an androgen-receptor pathway inhibitor (ARPI; these drugs include enzalutamide, abiraterone, apalutamide, and darolutamide) or a further addition of docetaxel to ADT plus ARPI.
In Parts 1 and 2 of this series, we have talked about how the double-barreled attack on mHSPC prolongs life and improves quality of life by reducing the complications of metastatic prostate cancer. We’ve also noted that many American men are not being offered this approach, and are being treated with ADT alone in early metastatic prostate cancer. And we’ve talked about one big reason why – because many doctors mistakenly think that if they use both “big guns” of treatment at once, they won’t have another weapon left to use down the road, or they have concerns about the side effects. Education is the best way to change this mindset, Agarwal says: education of clinicians as well as patients.
Financial Constraints
But there are other roadblocks, as well. One of them relates to the fact that in the U.S., medical care in general is expensive and complicated, and many medical practices rely heavily on a small team of people whose job is simply to be on the phone with insurance companies, every single day, advocating for patients.
“Using combination therapy is associated with more workload for clinicians and their practices,” says Agarwal, “especially if you don’t have enough support staff. Many solo oncology practices don’t have the support of an in-house nurse practitioner, pharmacist, or big team of financial people who can write letters or talk on the phone with insurance companies.” There are copay issues with combination therapy, he continues, and also issues arising from comorbidities – other health problems requiring other drugs that may interact with one ARPI versus another.
Here’s an example: “Eliquis® (a blood-thinning drug) is quite common. But it has an interaction with enzalutamide. You either have to talk with a primary care doctor or cardiologist to see if you can have Eliquis® switched to something else, or you have to fight with an insurance company to switch to abiraterone or darolutamide if they have enzalutamide as their preferred agent.”
With insurance and also with Medicare, out-of-pocket copays are a big problem for many patients. One option for the man on Eliquis® might be abiraterone, which has another major benefit: Abiraterone has been around long enough that it has “gone generic,” and is much less expensive than other ARPIs. “This man could get abiraterone for $170 a month. But many patients have zero copay for enzalutamide; it’s $15,000 per month, but their copay is zero.” If this man only has Medicare, “and he doesn’t have a backup insurance plan to help with the out-of-pocket costs, it can be very challenging to afford that monthly copay,” which could run into the thousands each month, depending on a patient’s insurance plan, and whether he – not to mention his spouse or partner – is on any other expensive medications.
What about a coupon? Unfortunately, coupons don’t always help, Agarwal continues. “Say you have a coupon from a pharmaceutical company for $200 for your copay. That is not considered by the insurance company as support for the copay. Instead, it’s considered as a contribution toward the base price of the drug, which is wrong.”
Agarwal has been advocating on Capitol Hill for legislation to help relieve the financial burden for patients with cancer. The recent Inflation Reduction Act contains a provision that allows Medicare to negotiate the price of some prescription drugs. Additionally, “patients on Medicare will have a $2,000 yearly cap on out-of-pocket prescription drug costs, starting this year,” says Agarwal, “so that should help.”
What can you and your doctor do to pave the way for success with combination therapy? A lot of groundwork, as we will discuss in Part 4.
