A cancer specialist has told Health Insurance that he could use a test not covered under existing private medical insurance (PMI) plans “about once or twice a week”, to help breast cancer patients make important decisions about treatment.
Dr Paul Dyson of Cumberland Infirmary in Carlisle has used Oncotype DX, the prognostic test featured in last months’ issue, approximately 25 times and found it “very, very useful”. The test is carried out on breast cancer tumours to assess the likelihood of the cancer recurring and the extent to which a patient is likely to derive benefit from undergoing chemotherapy. It is not currently routinely funded by Bupa, AXA PPP healthcare or Aviva UK Health, the three largest PMI providers in the UK.
“For most of the patients it does not alter the current decision, but there is a certain subset of patients who do not want chemotherapy but are willing to be nudged in the right direction by a further test and that is how I have found it most beneficial,” said Dr Dyson.
“Some, after they have had the test, have opted not to have chemotherapy. Others have decided to have chemotherapy based on the test. It works both ways. The art is discussing it with them beforehand and telling them that the test is not black and white. It does not say ‘you will not relapse so there is no point in having any further treatment’, it is shades of grey. The beauty is, it will tell you which patients are most likely to benefit from undergoing chemotherapy.”
He added that he was “loath to mention it because most people cannot afford it”.
‘MASSIVE DIFFERENCE’
A breast cancer patient who paid for the test out of her own pocket (at a cost of £2,394) has told Health Insurance about the impact the results had on her life. After receiving her results, which indicated that her cancer was unlikely to recur, she decided not to undergo chemotherapy.
“It’s a shame it’s not widely available to people,” she said. “It made a massive difference to me. Instead of being in the middle of chemotherapy I am about to start radiotherapy and hormone treatment.”
Genomic Health, the US-based manufacturer of the test, does not have a signed contract in place with any private medical insurers in the UK, but Jim Vaughn, the organisation’s vice president of international, said that the firm had had “a fair amount of reimbursement” from insurers when pre-authorisation had been sought.
Insurers, including Bupa, have told Health Insurance that they require further evidence that the test changes treatment decisions, before they will routinely fund it. Medical representatives of the insurers also cited the fact that significant numbers of patients who undertake the test will be told they have a “middle” risk of their cancer returning, posing challenges when it comes to making decisions about whether or not to undergo chemotherapy. A trial – TAILORx – is currently underway to evaluate the effect of chemotherapy on this group. The results may prompt insurers to look more favourably on the test.
However, the issue highlights the increasing number of “grey areas” that UK PMI providers face when considering which drugs and treatments to fund. WPA, for example, is already funding the test – but on a discretionary basis only.
“It’s all about what the patient needs in our book,” said Charlie MacEwan, corporate communications director at WPA. “It is not on the benefit schedule but we will make a decision on a case by case basis. With these kinds of pioneering treatments that discretion must remain. We will act in the best interest of the customer.”
In the US, both the state-funded Medicare and private health plans covering over 90% of insured lives cover the test, which has been evaluated in thirteen clinical studies involving more than 4,000 breast cancer patients worldwide.
“Getting US insurers to fund the test, I would have said it was not easy,” said Vaughn. “What really started to move were individual patients who were interested in it – either they wanted to have chemotherapy or they did not, but they wanted to know what was happening with their own tumour. There was very strong support from oncologists and surgeons and patients forced carriers [insurers] to look at the data and evaluate it.”
In the US, patients with insurance can request an expert review of their claim for a medical intervention. If two out of three expert reviewers support the patient the insurer must reimburse the payment and any costs associated with the review. Vaughn said that Genomic Health was in discussions with England’s National Institute for Health and Clinical Excellence (NICE) with regard to securing approval of the test for use in the NHS but that no appraisal is currently underway, although a board is being assembled to look at the field of genomics.
In the meantime, patients are funding the test privately or relying on the discretion of insurers.