The recent senate inquiry into “Availability of new innovative and specialist cancer drugs in Australia” brought timely attention to our Australia’s approach to access and funding of cancer medications. Perhaps unsurprisingly the matter of access to medications for palliative care was not seen as the chief focus of this review, but on closer attention perhaps it received more discussion than was realised.
In one session Dr Christopher Steer (@drcbsteer) discussed the results of recent phase 1 trials of chemotherapy for melanoma demonstrating compelling evidence of effect and cited his concern that delays in access due to government processes may mean that persons who could benefit from such medication may never get a chance to use it. This is an important issue for novel anti-cancer treatments, but in discussing it is relevant to note that many such medications are essentially novel palliative treatments. Innovative as they may be such medications are often directed towards the palliative management of incurable disease. As highlighted by Palliative Care Australia in their submission to the inquiry, dialogue about access to such medications in Australia is of critical importance, but in recognising many of these as palliative treatments it also highlights the need for attention on broader access issues to palliative care medicines in our community.
Access to palliative care medications is complicated by numerous issues including funding and the ready availability of the medications themselves. Funding of pharmaceuticals through the PBS requires application through a stringent evidence based assessment. The limited evidence for many palliative treatments and the limited corporate interest in investigating such indications for medications which are often off patent mean that many medications are not available through PBS for what are their assumed palliative indications. Medications that are used but not under subsidy for palliative indications may be clinically appropriate but prove too costly for patients to afford. Research organisations such as PaCCSC have been building the evidence base for palliative treatments to improve access to appropriate medications working with the TGA and PBAC. However, the deliberate pace required to build the evidence base may be lagging behind the increasing use of palliative medications.
Evidence from the AIHW demonstrates an increasing number of prescriptions for palliative indications with 82% of prescriptions coming from GPs. On the surface this is encouraging and suggests improving access however this tally only reflects PBS scheduled medications. As described in a recent Australian article from Tim To and colleagues off-label and unregistered prescribing is a common occurrence in palliative care but even among palliative care specialists complete understanding of the status of such medications is lacking. It is unclear how widespread this practice is among non-specialists, though it may be fair to assume that it is also an area incomplete understanding among this broader prescriber base. These uncertainties compound issues of access to palliative care medications as the variation of registration and funding status, evidence base and cost are not only likely to effect prescribing practices, but also limit our understanding of how and when these medications are used in palliative care.
Access issues may also be compounded by the availability of the medications themselves. For unregistered medications and newer opioid therapies in particular availability in the community setting can be another barrier. Local pharmacies may not carry the medications required which may make urgent symptom management a complex affair. Specialist services, who may encounter this problem often, may have worked out ways of circumventing these issues with supply through certain providers or hospital services. While this may improve access for patients receiving specialist services it is again important to acknowledge that the majority of palliative care is provided by non-specialist services who may not have the knowledge, or resources to ensure timely supply of such medications.
While arguably not focused on this issue the ongoing discussion about access to cancer medications in our society provides a great opportunity to refocus our attention on palliative medications and prescribing. Great strides forward have been made in understanding access issues for palliative medications in our region, though more work need to be done to improve timely, affordable and appropriate access to medications in palliative care.
Thanks for sharing this Michael. I think it’s an important area for palliative care professional groups and PCA to advocate for patients. For example, consider the effects on palliative care patients if paracetamol is removed from the PBS as recently suggested. Public commentary around the matter suggests a poor understanding of how the PBS works and also the fact that people with chronic pain may require regular paracetamol, often in a blister pack prepared by a pharmacist.