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breast cancer care access: the barriers patients still face and what's being done about them
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access to breast cancer screening and treatment has been rapidly changing over the years. with big pushes from advocacy groups and physician-led groups, the screening age was lowered to 40 so more people would have the opportunity to catch breast cancer earlier if it develops before the age of 50.
new therapies have also emerged, making it easier than ever to treat breast cancer, allowing people to focus on quality of life as opposed to just surviving the diagnosis.
while these positive changes continue to highlight the dedication to breast cancer care access in canada, there are still some issues people face.
“access to treatment is basically still a postal code lottery,” said kimberly carson, ceo of breast cancer canada. “with the new treatments that are coming out, a lot of them require testing to make sure that the drug is going to work or that canditate’s a good candidate for that type of medication, and it’s very timely. so, if we don’t have the testing in a timely manner, then they don’t have access.”
dr. mita manna, a medical oncologist in saskatchewan, echoes this same sentiment, saying that while medical innovation for breast cancer care has come a long way, canadians are often left playing the waiting game when it comes to getting the medication into patients’ hands.
“we can see delays in accessing drugs in the public health care system,” she said. “[but] we might not be able to utilize it for our patients for, usually, on average, about one or two years after the fact. so that has, of course, led to concerns and the need to try and ensure that we can access these drugs in a timely fashion for our patients because time is of the essence.”
the red tape barrier
before a drug can get to market and help patients directly, it has to go through a lot of red tape. the “lifespan of a drug” starts at clinical trials, where evidence is gathered to ensure that it’s both safe and beneficial. that data is sent to health canada for approval, and once they give their go-ahead, it must undergo a health technology assessment through the canadian drug agency (cda), or the institut national d’excellence en santé et en services (inesss) in quebec.
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“they essentially look at the health economics of things, and they state that, yes, the provinces should reimburse these particular agents and come up with funding algorithms,” said dr. manna.
they review evidence and come to a decision, but that’s not the end of the road. each province must then finalize and negotiate prices so they can offer it to the people.
this lengthy process, which can span years, keeps medications that work well approved but unavailable under reimbursement plans, leaving patients to wait for something that could potentially be lifesaving.
“it is imperative that we have effective drugs available because if patients are having to wait a year or two, they might not have that time to wait that long to receive that important therapy,” said dr. manna.
carson notes that the system in place needs to move more in line with the rapid evolution of innovative therapies as well, because of the lengthy timelines.
“there’s no reason for that [taking up to two years], particularly when there’s a lot of other regulatory bodies that look at it long before it ever gets to us. the fda, if it’s an orbis drug, ontario took that step forward to say any orbis drug will be approved under their fast program.”
ontario’s fast program (funding accelerated for specific treatments) is exactly what it sounds like: a program designed to fast-track drug access. it works by providing patients with access to high-priority cancer drugs up to a year before it would be widely available under normal funding pathways. project orbis is a cooperative program coordinated by the u.s. food and drug administration (fda) that allows drug review and submission to happen concurrently with other regulatory partners, such as health canada.
“systemic change like that needs to happen, and it needs to happen faster. if we already know this medication’s safe, why are we waiting two years? if we already know the technology is good, why are we waiting?” said carson.
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the equitable access barrier
because each province negotiates drugs new to the market, some may get reimbursement faster than others. so, two canadians living with the same type of breast cancer in different provinces could have two very different experiences when trying to access a newer therapy that could benefit their specific type.
“we don’t see the same treatment even province by province or in major cities, but certainly the difference between rural geography and urban geography in what’s available,” said carson.
because people living across the country will have access at different times based on the policies in place and the requirements that each drug must pass to get into the hands of patients, it becomes a luck of the draw in terms of where people live and how optimal their cancer care access becomes.
but the goal is to make changes so that people won’t have to worry if they live in the ‘wrong’ place for their best health interests.
“the ultimate goal is to ensure that there is essentially access across canada and ideally that should be the case where there are very limited to no variations across provinces,” said dr. manna. “of course, there’s going to be some variation between provinces and that does exist, but ultimately, we want to make sure that, as i said, no matter where you live across the country, you have access to these agents.”
prevention and screening play a major role in survivorship of breast cancer, because catching it early provides the best possible outcomes, and while the current system is set on its old ways of treating over prevention, making changes in that regard can also provide equitable access.
“there needs to be more attention to modernizing the systems,” said carson. “we have no blood tests that we know can start to detect cancer. why are we not authorizing those yet in canada? why are we not embracing that technology?”
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she continued, “if we can catch it early, we can prevent it from becoming metastatic, and we can prevent you from not having a great survivorship outcome.”
eliminating barriers and celebrating progress
breast cancer canada has been working to eliminate barriers to diagnostic and treatment access, along with the real alliance, a coalition of oncology experts across the country that dr. manna is part of.
these organizations work with policymakers, researchers and others involved in the creation, approval and use of these drugs in patients and have continued to present new data that has changed the landscape for the better.
and several things have changed drastically, improving the way breast cancer is found and treated. for example, as mentioned above, the minimum screening age was lowered by a decade. there have also been some wins when it comes to breast cancer survival rates for all types, with many cases that are caught early leading to people overcoming breast cancer altogether and people with metastatic disease being able to live for up to 30 years.
“we already see that these organizations are recognizing the need to get these approvals done fast and for canada to also lead the way,” said dr. manna. “things are moving in the right direction … i’m hoping that these programs will continue to grow and become more robust and as clinicians, we are able to provide our feedback and our recommendations and our clinical insights in terms of where the priorities are.”
with the improvement of survival rates, as well, a new era of breast cancer treatment can now focus on quality of life and survivorship.
“we do see people surviving,” said carson. “so, what does that look like? how does survivorship impact the patient’s journey? do they go back to work? can they pick up their grandkids? can they do their daily activities? i would say that advances in the medical world, whether it’s treatment or technology or any of the life sciences pieces is really ramped up to have the same life expectancy and the same outcomes with less harm.”
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what needs to happen next is embracing a new system that is not only open to new technologies and ways of looking at breast cancer, but also focuses on timelines in terms of how quickly these technologies can be adopted, and how fast regulatory bodies can realistically move to bring cancer care to canadians when they need it most.
“we are in a public health care system, and we need to be judicious about how things are utilized and reviewed, but ideally, i would say within three or six months, being able to have publicly reimbursed access [is the goal],” said dr. manna.
the innovation taking place in terms of breast cancer is rapidly changing for the better with “physicians and clinicians and healthcare advocates across the country” working tirelessly together to make access and treatment that much more equitable and available, said dr. manna.
and with advocacy pushes and government bodies working together, the hope is to one day see “zero deaths from breast cancer in canada,” said carson.
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