Is the grass greener?

I have noticed that a number of the participants on this site are Canadians, which is only one reason I always keep my extra Canadian “u”s in my posts. There have been a few issues that have come up that might be different on the other side of the border, but for the most part, cancer is cancer and the questions are universal. However, a recent question on second line therapy prompted Dr West to wonder what happens in our more regulated health care system so I thought I’d provide a bit of a commentary. If you read my bio you will already know that I did all of my medical training in Canada but I did have the pleasure of spending a year in Nashville, Tennessee at the Vanderbilt-Ingram Cancer Center and University Medical Center. I spent this year in a lung cancer research fellowship that included at least 2 days a week in the clinics. So, although limited, I do feel that I have some sense of the similarities and differences in cancer care, at least in an academic setting.

Rather than get trapped in a debate about which country has a better system let’s just agree that there are good things and bad things about each one. Both could use some improving, neither is perfect, and both will need to evolve over time.

Access is usually the issue in Canada. We often seem to be “behind” the United States in terms of access to new drugs. Although we pay close attention to the rulings of the FDA, our own Health Canada carefully considers the evidence, data, and trials available for each new chemotherapy. And, even if a drug is approved for use in a given disease state, each province will have to decide if the drug will be paid for or not. If it is available then it is provided free, to everyone. If it is not covered by the province but it is approved by Health Canada, then patients can usually get access to it by paying for it themselves or sometimes through any additional health care insurance programs an individual patient might have. Additional health insurance is certainly not the norm, but it is relatively common. For example, pemetrexed (Alimta) is approved for use in the second line setting for advanced NSCLC, but most provinces do not pay for it (except in mesothelioma). It is paid for/covered in British Columbia, which is why I use it more than docetaxel (Taxotere) (mainly because of the hair loss issue), but I had no problem using the equally effective docetaxel before and I do not think that the other provinces are providing inferior treatment because they do not have it available.

There is a similar issue with erlotinib (Tarceva), which is covered by almost every province (and being reviewed by the territories) for use in second line if someone cannot take a taxane and for third-line treatment for any NSCLC. This approval is based on the trial (BR21) that demonstrated benefit in this particular group of people. It is not approved in first-line because the results for the studies that are testing that haven’t been released yet. I agree, it is tempting to give it a try first-line – why not? If it works later why shouldn’t it work first, right? Well, I’m not so sure, and I think looking before you leap might be wise sometimes.

For example, erlotinib works by itself, we saw that from the phase II studies in the 1990s. Chemotherapy agents seem to work best when we combine them together – carbo/taxol or gem/cis so it must be that all 3 together would work even better. Right? Except when this concept was tested on over 4000 people there was no benefit to adding in the erlotinib (or gefitinib). Good thing we tested it rather than just adding it in automatically.

That’s not to say I haven’t used erlotinib first line. In fact I have a clinical trial open right now that is testing this exactly, with a solid rationale and a thorough ethics review. Beyond trials, I must admit it makes me nervous, though in individual cases I think it is worth considering.

Yes, I admit that it is sometimes incredibly frustrating that I cannot have access to every new drug that comes up in any creative combination for as long as I want to use it for. But this is supposed to be an evidence-based practice; the people I’m treating deserve a rationale for what I prescribe. And I believe that as responsible physicians we do need to put some thought into the cost of what we’re recommending. There is not an endless health care budget, in Canada but also in the USA. Even at a patient level, is it worth spending the last few months of your life struggling to go to work so you won’t lose the insurance that pays for your $200,000 of chemotherapy that maybe only adds 2 weeks to your survival?

Someone will ask about Canadian waitlists – yes, this can be a problem. Sometimes it takes 2 weeks to get a CT scan or 2 weeks to book an appointment for palliative chemotherapy. That waiting can be very anxiety-provoking for patients and families. From a biological point of view, it’s hard to know how much difference a week or two makes. When it does make a difference, in a curative situation or in a medical emergency, there is no waiting.

So of course there are differences. Having worked in both countries, I see that there are a lot of misconceptions about the other’s systems and there is a huge amount of variability for individual situations. Hopefully we can learn from each other.