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Take a Chill, PillWhy oral cancer drugs are not all they're cracked up to be.

By Jessica WapnerPosted Tuesday, Oct. 21, 2008, at 1:09 PM ET

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Also, many insurers require patients to fill their prescriptions through mail-order pharmacies, resulting in delays and botched shipments. For example, one kidney cancer patient suddenly experienced inexplicable disease progression on a drug that had been working for months. It turned out that her most recent refill, left on her front porch when she wasn't home to receive the delivery, had gone bad in the summer heat. Mail-order pharmacies also require large refills, sometimes up to 90 days, a completely impractical measure for a disease whose treatment requires frequent dose adjustments. That factor alone leads to thousands of dollars of medicine wasted.

On the plus side, many oral drugs are now distributed exclusively by specialty pharmacies, which help manage cancer patients taking treatment at home. Staffed by oncology pharmacists, these businesses serve as surrogate doctors, calling patients regularly to check about side effects, issue refill reminders, and help answer questions. But the extra middleman, while often useful, can just as easily lead to confusion and miscommunication. For example, a specialty-pharmacy caseworker might not know about a change in dose level made by the patient's doctor, causing problems with the next refill scheduled to be sent by the specialty pharmacy. Or a caseworker might neglect to report all the details of a conversation about an ongoing side effect. Motives come into question, too: Many specialty pharmacies provide data to drug companies about what drugs a doctor is prescribing to what patients, giving companies that restrict distribution of their drugs to specialty pharmacies a competitive edge over those who provide their pills through regular retail outlets.

Government insurance doesn't make things any easier. Oral cancer drugs are covered under Medicare Part D, but with a serious catch. Part D covers the first $2,000 with a 25 percent co-pay, followed by a $2,850 coverage gap known as the doughnut hole, for which patients are completely responsible. After patients emerge from the doughnut hole, benefits resume for the rest of the year. Because oral cancer drugs are extremely expensive, a Medicare-insured cancer patient will enter the doughnut hole after a single prescription and may not be able to afford a refill. Back to the clinic administrator, who then spends hours locating a patient-assistance program, a charitable organization set up to help cancer patients afford their treatments. Disturbingly, most patients who receive such assistance are probably getting money from an organization that gets donations from the very drug company whose pills they cannot afford.

Every single oral cancer drug is covered by Medicare Part D, giving pharmaceutical companies an extra incentive to focus on this approach. But doctors receive zero revenue for administering oral therapy. By contrast, traditional chemotherapy, covered under a different area of Medicare (without a doughnut hole and with generally lower co-pays), accounts for about 80 percent of the average oncologist's revenue. The eventual economic ramifications for cancer-care professionals are unknown.

Oral cancer drugs are an ideal option for vast numbers of cancer patients. These at-home regimens are convenient, often do have milder side effects than traditional chemotherapy, and herald a new era for those suffering from a horrible disease. For a patient who clearly comprehends what side effects are normal, which are not, and other complicated health matters, at-home treatment may make good sense. Clearly, though, hurdles abound, and many patients and doctors are proceeding under the misconception that pill-based therapy is a snap.

A recent report from the National Comprehensive Cancer Network, one of the main U.S. organizations for cancer-care professionals, states that it will probably be a decade before any cancer regimen is entirely oral-based. That should give plenty of time to work out the kinks.