The cost of medicines for breast cancer can have a significant financial impact on women and their families.
While many of the medicines used in the treatment of breast cancer are available through the Pharmaceutical Benefits Scheme (PBS), which means they are available at a Government-subsidised price, not all breast cancer medicines are included.
"I really did think that all of the costs would be covered by Medicare, boy was I wrong" - Deanne
Many women tell us that they are uncertain as to why some breast cancer medicines are subsidised while others are not. It's often not clear who makes these decisions, and what sort of criteria they use.
The following information has been developed to provide a simple overview as to how breast cancer medicines are subsidised in Australia.
The process by which breast cancer medicines get subsidised
When a new treatment is first discovered, it needs to be thoroughly evaluated through clinical trials to determine whether it is safe and effective for people to use.
If the results of the clinical trials are shown to be favourable, the manufacturer/pharmaceutical company will submit an application to the Government's Therapeutic Goods Administration (TGA) to have the treatment approved. Once a medicine has received approval, this means that the medicine is safe, effective and can therefore be sold in Australia.
Following TGA approval a sponsor (usually the pharmaceutical company) can make an application to have the medicine added to the PBS.
Applications are forwarded to the Pharmaceutical Benefits Advisory Committee (PBAC) which is responsible for making recommendations to the Federal Minister for Health and Ageing about which medicines should be subsidised under the PBS.
The PBAC is an independent expert body of medical specialists, general practitioners, pharmacists, health economists and consumers that usually meets three times a year to consider applications. BCNA and professional groups such as Medical Oncology Group of Australia Incorporated (MOGA) sometimes work with the PBAC to speed up the process of approval for a subsidy for new breast cancer treatments that will provide major advances for women.
When assessing whether a medicine should be subsidised, the PBAC considers the overall clinical effectiveness of the medicine, as well as the cost effectiveness (value for money) of the medicine. In addition, the PBAC considers how the medicine compares with existing medicines used to treat the same condition.
The PBAC also considers community need or benefit through 'non health' outcomes, such as whether the medicine is more convenient to take, or whether there are other gains to the community apart from improved health.
For more detailed information about the general guidelines followed by the PBAC you may like to refer to the Department of Health and Ageing's information regarding the Role of the Pharmaceutical Benefits Advisory Committee.
If the PBAC considers that a medicine should be subsidised, the Pharmaceutical Benefits Pricing Authority (PBPA) will then negotiate with the sponsor regarding the proposed price of the medicine. Once a price has been agreed, and following final consideration by the Federal Minister for Health and Ageing, a medicine can then be added to the PBS. If a medicine is expected to cost more than $10 million per year, approval from the Federal Cabinet is also required before it can be added to the PBS.
While the PBAC considers applications for particular medicines to be added to the PBS, applications to have medical technologies and procedures (including diagnostic tests such as MRIs) subsidised under the Medicare Benefits Schedule (MBS) are instead considered by the Medical Services Advisory Committee (MSAC).
The MSAC is an independent scientific committee made up of individuals with expertise in clinical medicine, health economics and consumer matters, which advises the Federal Minister for Health and Ageing. Broadly, the MSAC considers such factors as the safety, clinical effectiveness and cost-effectiveness when evaluating whether the procedure should be subsidised.
Sometimes, women are required to undergo a test to determine whether they would benefit from a particular breast cancer medicine. For example a 'FISH', 'CISH' or 'SISH' test is required to determine whether a woman's breast cancer is HER2 positive, and whether she requires the treatment Herceptin or Tykerb. At present, reforms are attempting to improve the process for subsidising new tests to ensure that MSAC approval for the new test coincides with the PBAC approval for the related medicine.
Are there ways to access breast cancer medicines that are not subsidised?
Some breast cancer medicines are not subsidised and, as a result, women are required to pay the entire cost of the medicine. This can be very expensive for some medicines.
We know that it can be distressing for women if they are not able to afford expensive breast cancer medicines.
"It's wrong that drugs are available that are very expensive and put out of reach for a lot of people, so they're only available for the wealthy." --Mary
There are however some other options available to access expensive breast cancer medicines, which are outlined below.
Patient access programs
Some approved breast cancer medicines not subsidised under the PBS may be available through a patient access program, offered by a pharmaceutical company.
These schemes are offered at the discretion of the pharmaceutical company and the medicines are provided on a case by case basis. In some cases the cost of the medicine is shared by the woman and the pharmaceutical company. You may like to ask your oncologist about medicines available through these schemes.
Private health insurance
Some private health insurance policies may enable you to claim benefits towards the cost of your prescription medicines, which means that you may have lower out-of-pocket expenses.
If you have private health insurance you may like to ask your insurer if you are able to claim benefits towards the cost of your prescriptions.
"My private health fund covered most of my expenses, Medicare covered some and there were a few out-of-pocket expenses." --Kassandra
Other options to access breast cancer medicines
In some circumstances your oncologist may be able to access breast cancer medicines that are not available for use in Australia. However it is always advisable to discuss any options such as this very carefully with your oncologist. Your oncologist is required to document your informed consent to the use of an unapproved medicine and to notify the TGA of any unexpected side effects.
"Even though women discuss a range of serious matters with their doctors, many women are still reluctant to voice their financial concerns with their doctors. I advise all women to determine exactly what their 'out of pocket' expenses will be when making appointments. I advise them to discuss with office staff at time of booking appointments if they have concerns regarding costs." --Liz, Breast Care Nurse
Research conducted jointly by BCNA and the University of Sydney has shown that women want to know about all treatment options, including high cost treatments. However we know that often, health professionals are reluctant to discuss expensive treatment options with a woman, if they believe that the woman may not be able to afford the treatment, for fear of causing her distress.
We urge all health professionals to discuss all treatments options with women, so that they can make an informed decision about the best treatment options for them.
