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

Dixon T S Woon; Thenappan Chandrasekar; Lorne Aaron; Naveen S Basappa; Kim N Chi; Henry J Conter; Geoffrey Gotto; Sebastien J Hotte; Shawn Malone; Fred Saad; Bobby Shayegan; Laura Park-Wyllie; Robert J Hamilton

doi:10.5489/cuaj.5378

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

Can Urol Assoc J. 2018 Oct;12(10):328-336. doi: 10.5489/cuaj.5378. Epub 2018 Jul 16.

Authors

Affiliations

¹ Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.
² Service d-Urologie and Centre de la Prostate, Hôpital Charles LeMoyne, Longueuil, QC, Canada.
³ Southern Alberta Institute of Urology, University of Calgary, Calgary AB, Canada.
⁴ BC Cancer Agency, University of British Columbia, Vancouver, BC, Canada.
⁵ William Osler Health System, University of Western Ontario, Brampton, ON, Canada.
⁶ Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada.
⁷ The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
⁸ Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, QC, Canada.
⁹ Medical Affairs, Janssen Inc., Toronto, ON, Canada.

Abstract

Introduction: Treatment using abiraterone acetate plus prednisone, enzalutamide, cabazitaxel, and radium-223 (Ra-223) improves 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.

Methods: 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.

Results: Both androgen receptor-axis-targeted therapies (ARATs), abiraterone acetate plus prednisone and enzalutamide, are funded by provinces in the pre-and post-chemotherapy setting, however, sequential ARAT use is not funded. "Sandwich" therapy, where one ARAT is used pre-chemotherapy and a second is used upon progression on chemotherapy, is funded in six provinces: Ontario (ON), Alberta, New Brunswick, Prince Edward Island (PEI), Nova Scotia (NS), and Newfoundland and Labrador. Ra-223 is funded in five provinces: ON, Quebec (QC), British Columbia (BC), Saskatchewan, and Manitoba to varying degrees; ON allows Ra-223 either pre- or post-chemo (not both); QC allows Ra-223 post-chemo unless chemo 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 fist-line treatment for mCPRC or in combination with other agents. In ON, BC, QC, and PEI, cabazitaxel is not funded after progression on an ARAT in the post-chemotherapy setting.

Conclusions: 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.