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Controlling Emesis: What Is It Worth?

Fox Medical Oncology, Center, Paoli, PA

To the Editor:

I would like to respond to a recent article in the Journal of Clinical Oncology entitled, "American Society of Clinical Oncology Guideline for Antiemetic Oncology: Update 2006."¹ These guidelines are always informative and helpful. In addition, they are ammunition for the ongoing battle between oncologists and insurance companies in an attempt to strike the proper balance between the highest quality oncologic care possible and care that is realistic and affordable. A quote from the recommendations' paragraph summarizes the article as follows: "The three-drug combination of a 5-hydroxytryptamine-3 (5-HT₃) serotonin receptor antagonist, dexamethasone, and aprepitant is recommended before chemotherapy of high emetic risk. For persons receiving chemotherapy of high emetic risk, there is no group of patients for whom agents of lower therapeutic index are appropriate first-choice antiemetics." Unfortunately, I have learned through experience that there is one group of patients for whom this combination in not an appropriate first choice. This group of patients are those who cannot afford the out-of-pocket expense for these medications.

Specifically, aprepitant has been a problem of late. One patient returned with my prescription and said, "This will cost over $500. Do I really need it?" Instead of showing the patient the guidelines,¹ I initially fumbled around for samples, which are not available due to drug company sampling policies, and replied, "No. We'll do the best we can with the resources we have."

I am sure that other oncologists share this experience of trying everything, including allowing their practice to subsidize some agents that are not covered adequately in today's insurance morass. Nonetheless, there is only so much any individual can do. It is often bitter to contemplate at the end of the day the old gentleman, who had refused help from myself and others for these necessary medications because it would compromise his pride and dignity, sitting at the dinner table trying to decide whether his resources should be spent on dinner or medication. In a society like ours, having to make choices like this is unconscionable.

Author's Disclosures of Potential Conflicts of Interest

The author indicated no potential conflicts of interest.

REFERENCE

1. Kris M, Hesketh PJ, Somerfield MR, et al: American Society of Clinical Oncology Guideline for Antiemetics in Oncology: Update 2006. J Clin Oncol 24:2932-2947, 2006[Abstract/Free Full Text]

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