TORONTO - A move to take advantage of rare advances in lung cancer treatment is being undermined by slow action on the part of provinces to pay for testing to determine which patients will benefit from the drugs, a new report suggests.
The work, from the Cancer Advocacy Coalition of Canada, says all provinces should pay for the tests needed to figure out who should be taking the expensive drugs, described by the author of the report as a ray of light at the end of a tunnel.
"This is a huge advance in a disease in which everybody admits we've had no good news ever," said Dr. David Saltman, a medical oncologist with the B.C. Cancer Agency.
The drugs he referred to are erlotinib (sold as Tarceva), gefitinib (Iressa) and crizotinib (Xalkori). The first two target lung cancers in which the patients have mutated forms of the EGFR gene and the latter has been shown to be effective against lung cancers where a mutated version of the ALK gene is present.
The gene mutations are seen in a small subset of lung cancer patients — more precisely people with a type of non-small cell lung cancer known as adenocarcinoma. Saltman said about 15 per cent of people with adenocarcinoma have the EGFR mutation and between two and seven per cent have the ALK mutation.
People who are responsive to the drugs are more likely to be younger, female, people who never smoked, and of Asian heritage. And some provinces use that type of general descriptive information to try to home in on who should be tested for the mutations, Saltman said. But he noted the mutations don't always hold to a type, saying he has had some older male patients who smoked who have one of the mutated genes.
"We can't select who should have testing on the basis of their clinical characteristics. We have to select on the basis of their molecular characteristics. It's just not an ethical thing to do," Saltman said at a news conference called to release the coalition's annual cancer care report card.
"We should be testing everyone (with adenocarcinoma),"
The combined cost of the tests can be in the range of $500 to $600 per person.
The drugs are not a cure. But they offer real gains in patients in whom they work, Saltman said, and save the health-care system money in doing so.
Response to the drugs among people with the mutations can be in the 60 to 80 per cent range, with progression-free survival approaching a year, Saltman said. With standard chemotherapy, between 15 and 20 per cent of adenocarcinoma respond, he said, and the average progression-free survival period is about three months.
"So these drugs are very effective, but if you can't test for them, you can't give the drug."
He said some provinces — British Columbia, Alberta and in some cases Manitoba — are paying for the tests. In other provinces, some testing is being done through research projects or with funding from the test makers. And in some places, Saltman said, the testing is not being done.
The testing issue was one of several the report card touched on. Another was the variability in the insurance coverage Canadians have for access to smoking cessation aids. The report suggested more Canadians who smoke might quit if they better coverage for things like nicotine replacement products and smoking cessation drugs.
It suggested smokers in Atlantic Canada are particularly hard hit because a combination of factors: the prevalence of smoking there is higher than in other parts of the country and more people in the region have no drug insurance.
The report said it's hard to understand why jurisdictions that fund the cost of medication to treat high blood pressure and high cholesterol wouldn't pay for drugs that help people quit smoking.
The report card also looked at the effect of bans on smoking in cars transporting children, saying evidence suggests these policies have reduced children's exposure to second-hand smoke.
There had been concerns that bringing in bans on smoking in cars while children are present would lead to an increase in exposure to second-hand smoke elsewhere, the report notes. The thinking was that smokers might light up more at home if they cannot smoke in cars when their children are with them. But the study said that concern hasn't materialized.
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