Disparity in public funding of therapies for metastatic castrate-resistant prostate cancer across Canadian provinces

• Published in: Canadian Urological Association journal Vol. 12; no. 10; pp. 328 - 336
• Main Authors: Woon, Dixon T S, Chandrasekar, Thenappan, Aaron, Lorne, Basappa, Naveen S, Chi, Kim N, Conter, Henry J, Danielson, Brita, Hotte, Sebastien J, Malone, Shawn, Saad, Fred, Shayegan, Bobby, Park-Wyllie, Laura, Hamilton, Robert J
• Format: Journal Article
• Language: English
• Published: Canada Canadian Medical Association 01.10.2018
• Subjects: Original Research
• ISSN: 1911-6470; 1920-1214
• DOI: 10.5489/cuaj.5378

Treatment using abiraterone acetate, enzalutamide, cabazitaxel, and radium-223 (Ra-223) improve overall survival (OS) and quality of life for patients with metastatic castrate-resistant prostate cancer (mCRPC). Despite their proven benefits, access to these therapies is not equal across Canada. We describe provincial differences in access to approved mCRPC therapies. Data sources include the pan-Canadian Oncology Drug Review database, provincial cancer care resources, and correspondence with pharmaceutical companies. Both androgen receptor-axis-targeted therapies (ARATs), abiraterone acetate plus prednisone and enzalutamide, are funded by provinces in both pre-and post-chemotherapy settings; however, sequential ARAT use is not allowed. "Sandwich" therapy, where one ARAT is used pre-chemotherapy and a second is used upon progression on chemotherapy, is funded in Ontario (ON), Alberta, New Brunswick, Prince Edward Island (PEI), and Newfoundland & Labrador. Ra-223 is funded in ON, Quebec (QC), British Columbia (BC), Saskatchewan, and Manitoba to varying degrees: ON allows Ra-223 either pre- or post-chemotherapy (not both); QC allows Ra-223 post-chemotherapy unless chemotherapy is not tolerated; BC allows Ra-223 if other life-prolonging mCRPC therapies have been received or ineligible. Cabazitaxel is funded in all provinces post-docetaxel, except QC and PEI. Cabazitaxel is not funded as first-line treatment for mCPRC or in combination with other agents. In Ontario, cabazitaxel is not funded after progression on an ARAT in the post-chemotherapy setting. While all provinces have access to docetaxel and ARATs, sandwiching sequential ARATs with docetaxel is funded only in select provinces. Ra-223 and cabazitaxel access is not ubiquitous across Canada. Such inequalities in access to life-prolonging therapies could lead to disparities in survival and quality of life among patients with mCRPC. Further research should quantify interprovincial variation in outcomes and cost that may result from variable access.