Financial toxicity greater for oral therapies in advanced prostate cancer

Investigators found that the total out-of-pocket costs associated with oral therapies for prostate cancer were approximately 18 times higher compared with ADT.

Investigators recently found that out-of-pocket costs for patients with advanced prostate cancer were higher for those receiving oral therapies compared with those receiving androgen deprivation therapy (ADT) or chemotherapy.1

"Further work is needed to assess financial toxicity in this population using objective instruments," Daniel D. Joyce, MD.

"Further work is needed to assess financial toxicity in this population using objective instruments," Daniel D. Joyce, MD.

The study authors conducted a review of existing literature to assess the financial burden associated with oral treatments for advanced prostate cancer compared with other options.

Data from a recent analysis showed that the total out-of-pocket costs associated with oral therapies were approximately 18 times higher compared with ADT after adjustment for patient baseline characteristics, resulting in an estimated increase of $2581 annually.2 In comparison with nonandrogen system therapies such as chemotherapy, the annual estimated cost increase over oral therapies was $1830. Further analysis showed that 80% of the treatment-related out-of-pocket costs were attributed to approximately 20% of the patients included in the study.

The authors also found that patients with Medicare, Medicaid, and those who are uninsured had higher rates of mortality compared with those on private insurance.3 The authors suggest that this may be due to patients’ hesitancy to initiate oral treatments due to the payment structure. One study pointed to this, finding that the expected out-of-pocket costs affected whether patients refilled their prescriptions for oral anticancer agents.4

These high out-of-pocket costs can be mitigated in part through the use of patient assistant programs (PAPs), which led to minimal out-of-pocket costs.5 These are currently underutilized, though, with one study finding that as few as 5% of patients receiving oral therapies utilize PAPs.6

Other efforts, such as Medicare low-income subsidies and recent policy efforts such as the Oncology Care Model and the Inflation Reduction Act of 2022 can help to offset costs for some patients as well. A Medicare beneficiary who did not have low-income subsidies could pay over $10,000 per year for treatment with an oral therapy such as darolutamide (Nubeqa).7

On top of the burden associated with direct costs, there are also the indirect costs associated with treatment, such as time, money spent on travel, and forced early retirement, which the authors argue need to be studied further.

In correspondence with Urology Times®, co-author Daniel D. Joyce, MD, concluded, “Currently, little is known regarding the indirect costs from these treatments, and further work is needed to assess financial toxicity in this population using objective instruments. Physician engagement in cost discussions is warranted to help mitigate financial toxicity from these treatments. Such investment from prescribers may decrease health care spending, improve patient satisfaction, and improve treatment adherence.” Joyce is a urologist at Mayo Clinic in Rochester, Minnesota.


1. Joyce DD, Dusetzina SB. Financial toxicity of oral therapies in advanced prostate cancer. Urol Oncol. Published online April 5, 2023. Accessed April 10, 2023. doi:10.1016/j.urolonc.2023.03.002.

2. Joyce DD, Sharma V, Jiang DH, et al. Out-of-pocket cost burden associated with contemporary management of advanced prostate cancer among commercially insured patients. J Urol. 2022;208(5):987-996. doi:10.1097/JU.0000000000002856

3. Suh W, Master S, Liu L, Mills G, Shi R. The effect of payer status on survival of patients with prostate cancer. Cureus. 2021;13(2):e13329. doi:10.7759/cureus.13329

4. Doshi JA, Li P, Huo H, Pettit AR, Armstrong KA. Association of patient out-of-pocket costs with prescription abandonment and delay in fills of novel oral anticancer agents. J Clin Oncol. 2018;36(5):476-482. doi:10.1200/JCO.2017.74.5091

5. Jeong AY, Schwartz EB, Roman AR, et al. Characterizing out-of-pocket payments and financial assistance for patients prescribed abiraterone and enzalutamide at an academic cancer center specialty pharmacy. JCO Oncol Pract. 2022;18(2):e284-e292. doi:10.1200/OP.21.00168

6. Felder TM, Lal LS, Bennett CL, Hung F, Franzini L. Cancer patients’ use of pharmaceutical patient assistance programs in the outpatient pharmacy at a large tertiary cancer center. Community Oncol. 2011;8(6):279-286. doi:10.1016/S1548-5315(12)70023-2

7. Dusetzina SB. Your money or your life – the high cost of cancer drugs under Medicare part D. N Engl J Med. 2022;386(23):2164-2167.doi: 10.1056/NEJMp2202726

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