We found that being younger than 65 years old, being indigent, and having no health insurance were the strongest predictors of using a PAP. This finding was expected, given that US adults younger than age 65 are ineligible for outpatient prescription medication coverage through Medicare Part D. However, contrary to expectations, about 45% of PAP users had either private or governmentsupplied health insurance. Because it is not uncommon for cancer patients to endure economic hardship (including bankruptcy) when trying to finance their care,13 healthcare professionals could recommend PAPs and other relevant assistance programs to all of their cancer patients.
With the expansion of health insurance through the Patient Protection and Affordable Health Care Act of 2010, it is hoped that the need for cancer patients to enroll in PAPs will be diminished; yet, given the reality of the high cost of anticancer agents, reimbursement policies for these agents, and tiered formularies among insurers leading to high outof- pocket costs for patients, the need for PAPs is likely to remain. PAPs can be a viable option for some patients, but healthcare professionals should be aware that there are a number of concerns about these programs, including their complex and burdensome application process and often limited variety of available drugs.14
This study is not without its limitations. First, we may have underestimated our sample of PAP patients due to the fact that MDACC did not electronically or systematically track the use of PAPs within its pharmacy database at the time of the study. The institution is in the process of developing such a system.
Second, the data used in this study cannot be assumed to reflect a “closed pharmacy” setting because some patients, particularly those who have health insurance with prescription medication coverage, may have received some of their medications from outside pharmacies.
Third, because insurance status is not necessarily a static characteristic, insurance status in this study was classified based on that at the time of registration with MDACC’s financial department, and no account was taken of changes that might have occurred.
Last, our results are not necessarily generalizable to all cancer populations, time periods, or settings. Cancer patients treated in academic centers such as MDACC may differ from those who are treated in community settings. In particular, fewer than 10% of patients at MDACC qualified for indigent financial assistance in 2007,15 which is likely to have impacted the number of patients who were potentially eligible for PAPs. It is also likely that had our study been conducted prior to the implementation of Medicare Part D, our sample of PAP patients would have been older. Nevertheless, our results may be generalizable to cancer patients receiving care in other academic cancer centers.
Conclusion This study builds upon a previous description of implementing PAPs in a comprehensive cancer center16 as well as contributes to our limited knowledge of the use of PAPs among cancer patients.6 Future studies should prospectively examine cancer patients’ experiences and satisfaction with PAPs from the process of applying to the point of receiving requested therapies and evaluate the effect of PAPs on cancer outcomes in various care settings. Multidisciplinary teams, including pharmacists and clinicians, should establish and recommend valid and relevant clinical endpoints for researchers to use in effectiveness studies of PAPs and cancer patients, particularly as they relate to oral anticancer agent use. Given that these oral agents represent more than 25% of cancer therapies in development,17 future studies of PAPs are ideal for evaluating concerns of accessibility, affordability, and compliance related to these agents.
MDACC is a unique resource for observers of PAPs, as it is the largest cancer center in the United States. However, few cancer patients at MDACC were eligible for and accessed PAPs in the outpatient pharmacy. Although smaller cancer centers may not be able to devote the same degree of financial and personnel resources to their patients as does MDACC, these centers could seek to build relationships with specific pharmaceutical companies that provide PAPs for the oral anticancer and supportive care therapies most commonly prescribed and administered at their centers. Scarce resources could also be utilized in other ways, such as by developing public-private risk pools for establishment of indigent care funds.
Acknowledgments: The authors thank Chun Feng, Jason Lau, and Oliver Max for their special assistance; Dr. Phoenix Do for her study design recommendations; and Karyn Popham for her editorial support. They especially thank Rebecca Arbuckle, RPh, for her support of this project. At the time of the study, Dr. Felder was supported by a Predoctoral Fellowship from The University of Texas School of Public Health Cancer Education and Career Development Program, funded by National Cancer Institute/NIH Grant R25-CA-57712-17.