Pancreatic enzyme replacement therapy (PERT) is often an essential component of the treatment regimen for patients with pancreatic cancer, but it can be very pricey.
“Out-of-pocket costs for a 30-day supply of enzymes for Medicare beneficiaries can be as high as $1000,” commented Arjun Gupta, MD, an oncology fellow at Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.
This can contribute to financial toxicity for patients who already have a high symptom burden and distress. The high cost of this supportive care has been underappreciated, he said.
In addition to its use for patients with pancreatic cancer, PERT is also prescribed to patients with chronic pancreatitis and cystic fibrosis. These enzymes can reduce symptoms of indigestion and improve nutrition for patients with exocrine pancreatic insufficiency, he explained.
“Out-of-pocket costs for two large pancreas enzyme capsules, which are often required for a meal, may be $15. And these need to be taken at every meal and may be more expensive than the meal itself,” he told Medscape Medical News.
Gupta led a new study that showed that among Medicare beneficiaries, the expected out-of-pocket costs for a 30-day supply of optimally dosed PERT averaged $999 across formulations. Patients’ costs, including deductibles and coinsurance, ranged from $853 to $1536.
The out-of-pocket costs were lower after patients met the deductible ($673; range, $527 to $1210) and continued to decrease after reaching catastrophic coverage ($135; range, $105 to $242).
The findings were presented at the Gastrointestinal Cancers Symposium (GICS) 2021.
Gupta noted that there has been a lot of publicity about very expensive anticancer drugs, but little has been said about the costs of products used in supportive care. “While it’s true that many patients cannot afford the drugs, there are patient-assistance programs where they can often get them free of charge,” he said. “But supportive care agents, such as those for constipation or the enzymes — all of those can nickel and dime you and end up being very costly.”
These agents add substantially to the drug cost burden. “Some patients also need insulin, which is also insanely expensive,” he said.
One of the reasons for the high cost of PERT is that there are very few options, and all the available products are brand-name agents. Gupta noted that clinicians often underprescribe pancreatic enzymes in clinical practice. “Because of this, we wanted to look at what are the estimated out-of-pocket costs for patients directly when they’re prescribed an optimal regimen of pancreatic enzymes,” he said.
For their study, Gupta and colleagues assessed PERT costs using the Medicare Part D formulary and pricing files for the first quarter of 2020. Point-of-sale and out-of-pocket costs for each PERT formulation were calculated among Part D stand-alone and Medicare Advantage prescription drug plans.
Costs were then assessed using three scenarios: the standard benefit design, with a $435 deductible and 25% coinsurance after the deductible is met; 25% coinsurance to fill a prescription after the deductible while in the coverage gap until the patient spends $6350 out of pocket; and 5% coinsurance once catastrophic coverage is reached.
Across 3974 plans nationwide, four formulations in 17 different doses were covered by Medicare plans during the study period. Doses ranged from 3000 to 40,000 lipase units, and the per-unit list price ranged from $1.44 to $13.89.
The point-of-sale price for a 30-day supply of optimally dosed PERT ranged from $2109 to $4840.
Gupta noted that a “good-sized meal often requires 80,000 units of lipase, or two of the very largest pills. Of note, these pills need to be taken meal after meal every meal throughout a patient’s life.”
Prescribers and dieticians try to find the least expensive options, including patient-assistance programs, but in the end, they are sometimes forced to underprescribe. “Some patients will go and buy over-the-counter pancreatic enzyme supplements, and it seems like a good way to cut costs,” said Gupta, “but it is not recommended for people with pancreatic cancer.”
The problem with these formulations is that they are not regulated. “The enzyme content in them is also miniscule, in the range of hundreds of units instead of the 50,000 units needed per meal,” he said. “Patients end up spending much more for ineffective therapies.”
The study received no outside funding. Gupta has disclosed no relevant financial relationships.
Gastrointestinal Cancers Symposium (GICS) 2021: Abstract 401. Presented January 17, 2021