Roxana Sultan | CHP | 17 OCT 2019
According to the latest statistics from the Canadian Cancer Society, about 1 in 2 Canadians will develop cancer in their lifetimes, and 1 in 4 will die of the disease.[i] In the past, most cancer chemotherapy treatment has been delivered through intravenous administration in the acute care setting.
With advances in medical research and treatment, many cancer medications can now be taken at home. It is estimated that more than 50% of new cancer drugs are formulated for in-home administration.[ii] This results in lower hospital infrastructure utilization and human resource costs, and enables patients to safely receive care in the comfort of their own homes, minimizing the risk of nosocomial infections, lowering travel costs, and reducing the amount of time that patients need to spend away from work and family during treatment.
The geography of Canada presents an important case for driving innovative approaches to cancer therapy. Patients living in the more rural and remote parts of the country need to travel long distances to access hospitals where they can receive intravenous chemotherapy. The specialty knowledge required to safely prepare and deliver complex and often dangerous chemical treatments can be limited in more isolated regions. With the loss of a single specialist in smaller centres, there can be a complete halt to the organizational capacity to deliver chemotherapy, as was the case in the Haida Gwaii archipelago earlier this year when the Northern Health Authority was unable to recruit a new specialty-trained pharmacy technician, despite offering substantial incentives to fill the position.[iii]
A 2017 Cochrane review showed that amongst patients with colorectal cancer treated with the aim of cure, disease-free survival, and overall survival, there was no statistically significant difference in outcomes between those who received oral chemotherapy versus intravenous treatment.[iv] Take home oral treatments offer an innovative, patient-centred, and more efficient mechanism for delivering high quality, evidence based cancer treatment to Canadian patients.
Under the Canada Health Act, prescription drugs administered in Canadian hospitals are provided at no cost to the patient; however, outside of the hospital setting, provincial and territorial governments are responsible for the administration of their own publicly-funded drug plans.[v]
Given that the incidence of cancer spans the continuum of age and socioeconomic status, access to private insurance for coverage of take-home cancer drugs is variable amongst patients, as well as across provinces. As such, patients often encounter obstacles in accessing take home medications for cancer treatment, which can result in delays to treatment, or unnecessary utilization of hospital services.
Coordination of multiple reimbursement programs may be required for a single cancer patient to cover the cost of their take home treatment, and the process of obtaining authorization and reimbursement of approved cancer medications can be time consuming and challenging, particularly for patients and families grappling with a cancer diagnosis and its emotional and economic impact.
It is noted that Canadian caregivers are given 26 weeks of paid time off to care for a loved one living with cancer through the Compassionate Care Benefit; however, those actually living with cancer are only given 15 weeks of paid time off through the Employment Insurance Sickness Benefit. In addition to the potential economic burden of unpaid leave from employment, insufficient reimbursement and out of pocket expenses can present yet another economic hurdle for Canadian cancer patients.
One in six Ontario cancer patients report that their out-of-pocket expenses are significant or unmanageable.[vi]
The Atlantic provinces have different systems for intravenous versus take-home cancer therapies, with funding for the latter covered through a mix of private insurance, special programs, or out of pocket expenses.[vii] In Quebec, eligible take-home cancer treatments qualify for public coverage, though a deductible based on income may be required to be paid.[viii] In Manitoba, Saskatchewan, Alberta, and British Columbia, patients can also get coverage for take-home therapies.
A system in which some Canadians have access to modern cancer treatments and some do not presents an opportunity for all provinces to keep pace with innovation in cancer treatments. Provinces need to work to reduce barriers for Canadians to access the best possible cancer services and minimize the economic and personal burden of managing a cancer diagnosis, so that we do not simply transfer costs of care from health service institutions to the pocketbooks of cancer patients and their families.
The federal government has undertaken initial steps towards implementing a national pharmacare program. Questions will need to be addressed as to whether Canadians currently accessing cancer drug coverage through private insurance plans would be at risk of losing coverage for certain – or even all – therapies if their provinces shift to include some take home cancer therapies on their formularies, or to participate in a national pharmacare program, particularly if employment-based health benefits begin to be taxed as income following adoption of the national plan.
It is critical that Canada’s system of public health coverage keep pace with innovation in cancer therapy, particularly as escalating numbers of Canadians are impacted by cancer each year. This will require a carefully designed approach aimed at reducing disparities in access to innovative cancer treatment and mitigating unintended loss of current coverage for Canadians with cancer.
Roxana Sultan, Vice Chair and Member, Board of Directors, Canadian Cancer Society Ontario Division. The opinions expressed in this article are the independent views of the author and do not necessarily reflect the views of the author’s employers or affiliated organizations.
[i] https://www.cancer.ca/en/cancer-information/cancer-101/canadian-cancer-statistics-publication/?region=on
[ii] https://www.cancer.ca/en/get-involved/take-action/what-we-are-doing/take-home-drugs-on/?region=on
[iii] https://www.ctvnews.ca/health/remote-health-care-tested-as-haida-gwaii-loses-iv-chemo-treatment-next-month-1.4443517
[iv] https://www.cochrane.org/CD008398/COLOCA_oral-versus-intravenous-chemotherapy-colorectal-cancer
[v] https://www.canada.ca/en/health-canada/services/health-care-system/pharmaceuticals/access-insurance-coverage-prescription-medicines.html
[vi] https://www.cancer.ca/en/get-involved/take-action/what-we-are-doing/take-home-drugs-on/?region=on
[vii] https://www.cancer.ca/en/get-involved/take-action/what-we-are-doing/take-home-drugs-on/?region=on
[viii] https://www.cancer.ca/en/get-involved/take-action/what-we-are-doing/take-home-drugs-on/?region=on