In the adjusted model, patients who were indigent (OR = 16.95; 95% CI: 6.845, 41.960), uninsured (OR = 4.60; 95% CI: 2.118, 9.970), and under the age of 65 years (OR = 2.31; 95% CI: 1.517, 3.509) were 2- to 17- fold more likely than others to be PAP users. Black patients were 31% (P = 0.020) less likely to access PAPs than were white patients.
Overall prescription medication fills The top-20 prescription medication fills from the MDACC outpatient pharmacy differed by PAP user group and PAP status. For PAP users, 88% of the most common medications obtained from PAPs were supportive care agents, including treatments of bacterial infections (n =887 fills; 49/month), antiemetics (n = 492 fills; 27/month), and gastroesophageal reflux disease (n = 492 fills; 27/month). Conversely, treatments for neutropenia and anticoagulation represented nearly half ($1.8 million) of the total charges avoided through PAPs to PAP users ($3.9 million). The most common medications not obtained from PAPs were for treatment of pain (PAP users = 292 fills/month, nonusers = 218 fills/month), versus only 13 fills/ month for pain medications from PAPs. Medications indicated to treat pain and nausea/vomiting accounted for the largest proportion of charges for medications not filled by PAPs for both PAP users and nonusers.
Anticancer agent prescription fills
For both PAP users and nonusers, the top-20 anticancer oral agent fills represented 93% (n = 2,892 of 3,105) of all anticancer oral fills (Table 6), with 16% (n = 454) of these oral fills being provided through PAPs. Among PAP users, anticancer agents from PAPs accounted for 40% of their total charges and 35% of the total number of agents. Temozolomide (Temodar; mean charge/fill = $3,346) represented the highest amount of total charges ($220,857) from PAPs, whereas imatinib (Gleevec; mean charge/fill = $5,372) and dasatinib (Sprycel; mean charge/fill = $5,221) accounted for the highest average charges per fill. Anastrozole (Arimidex; n = 178 fills; 10/month), capecitabine (Xeloda; n = 91 fills; 5/month), and temozolomide (n = 66 fills; 4/month) accounted for 70% of agents from PAPs. PAP users who were given bicalutamide received 100% of those agents from PAPs. Five of the seven oral anticancer agents with no fills from PAPs had initial US Food and Drug Administration approval years before 2000.
Discussion
At MDACC, PAPs are designed to help cancer patients overcome financial barriers to accessing oral supportive and anticancer agents. Over an 18-month observation period, less than 5% of the cancer patients at MDACC who received prescription medications from the outpatient pharmacy were enrolled in a PAP— and these PAPs provided 13% of their medication fills, representing an annualized $3.6 million in pharmaceutical expenditures. In interpreting our findings, several factors should be considered.
Oral anticancer agents accounted for 4% of all prescription medication fills during the study period. Comparatively, an analysis of the 2007 National Ambulatory Medical Care Survey showed that less than 1% of cancer patients were prescribed at least one oral anticancer agent.10 This finding indicates that both nationally and at MDACC, chemotherapy continues to be largely provided parenterally, as there is more of a financial benefit from intravenous therapies that are often reimbursed by insurers as well as PAPs.
In the outpatient pharmacy at MDACC, PAPs provided nearly onethird of oral anticancer fills for PAP users—totaling a mean of $500,000 per month in expenditures. However, three agents, anastrozole (for breast cancer), capecitabine (for breast and GI cancers, primarily), and temozolomide (for brain tumors) accounted for 75% of all of the anticancer agents provided by PAPs. We also found that pharmaceutical companies provided expensive newer, targeted, anticancer agents (primarily dasatinib and imatinib, the two agents with the greatest pharmaceutical per-person expenditures by the PAP program) through PAPs.
Although PAPs filled a strong and focused need for a small number of oral chemotherapy agents for some individuals with breast, GI, and brain cancers, they did not provide much benefit for a wide range of supportive care agents, particularly those that are schedule C and are used to treatcancer pain. Pain is the most prevalent symptom reported by cancer patients, 11 but there were few schedule C pain medications among the most common medications provided through PAPs. These substances are generally not provided by PAPs because of legal and substance abuse concerns.12 However, these medications were commonly prescribed to PAP users and PAP nonusers alike, outside of the PAP program. It would be important to evaluate the comparative success in treating pain among cancer patients at MDACC who receive a limited array of pain medications from PAPs (usually agents that are not substance-controlled by the Drug Enforcement Administration) versus treatment of pain experienced by patients whose medications are not reimbursed by PAPs.