Prohibit Step Therapy in Metastatic Cancer

TMA Testimony by Debra Patt, MD

House Insurance Committee
House Bill 1584 by Rep. Senfronia Thompson

April 2, 2019

Thank you Mr. Chairman, and members of the committee. Thank you for allowing me to testify today. My name is Dr. Debra Patt, I am an oncologist from Austin where I practice as a breast cancer specialist and serve as a Vice President for Texas Oncology, the largest independent, multispecialty cancer practice in the state with over 420 physicians. We treat over 60,000 Texans with new cancers annually across the state at over 175 sites of service and are a part of The US Oncology Network. Today I am testifying on behalf of the Texas Medical Association and its nearly 53,000 members statewide in support of HB 1584.

It is an amazing time to be an oncologist. I frequently tell my patients I feel like an infectious disease specialist in the era of penicillin. The innovation and development of chronic therapies have rendered cancer as a chronic disease like diabetes or hypertension for many patients. As a breast cancer specialist, I have many patients in my practice with metastatic breast cancer. Frequently I have the ability to choose between treatment options within the same class. Usually there are reasons why I prefer one drug over another.

When patients have metastatic estrogen-positive breast cancer, the most common kind, I will frequently start them on estrogen blockade in combination with a class of drugs called CDK 4 6 inhibitors. These drugs inhibit cycle-independent kinase. There are three of these drugs available on the market: Palbociclib, ribociclib, and abemaciclib, and they roughly triple progression-free survival. Many doctors would think these drugs are the same. They are not. Even though I do not have data to suggest that one treatment is more efficacious than another, there are frequently reasons why I prefer one drug over another for a specific patient.

One of my patients has inflammatory bowel disease (and chronic diarrhea) in addition to her metastatic breast cancer. Abemaciclib has a toxicity of chronic diarrhea. The other two agents do not. Abemaciclib would be a poor choice in this patient. The side effect would likely render her noncompliant and unable to maintain dose intensity.

Conversely, I have another patient with metastatic disease to her brain. Abemaciclib is the only drug in this class that has demonstrated efficacy by reducing brain metastasis in patients with metastatic breast cancer to the brain. Abemaciclib is an optimal choice for this patient.

What I hope the committee appreciates is that patient care decisions should remain between the doctor and the patient. Fail-first therapies and step therapies for therapeutic intervention are inappropriate in patients with metastatic cancer because there are so many reasonable reasons why clinicians and patients may prefer one therapy over another. 

If systemic therapy were implemented among patients with metastatic cancer, it would prohibit my ability to use my experience and knowledge to benefit my patients optimally.

Step therapy and fail-first therapy are already being implemented across some insurance plans in patients with metastatic cancer. I am routinely advised by my partners of patients who have had to initiate an inferior therapy prior to initiating a more effective therapy.

In some diseases, step therapy may not have severe consequences when patients’ symptoms are less controlled or a disease has moderate control. Metastatic cancer therapy requires protection from these utilization management techniques as the consequences of less control are grave.

Thank you for your consideration and I am happy to answer any questions.

Last Updated On

April 02, 2019

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