Opinion | I Can’t Guarantee Your Next Round of Chemo

“We are running low on cisplatin.”

“The e-mail came. We are out of carboplatin.”

“How do I prioritize which patients can receive the chemotherapy drugs?”

“I can’t give my patients the life-saving chemotherapy that they need.”

These are comments that have been shared in the media by oncologists throughout the country as a response to the chemotherapy drug shortages that started earlier this year. While drug shortages do happen often, the extent of this chemotherapy shortage appears unprecedented as it may be impacting as many as 500,000 Americans.

As an oncologist, I aim to be honest and transparent with my patients about their diagnosis and treatment options. I strive to be realistic about their prognosis and the side effects they may experience. Initially, the shortages seemed to be far away and were not directly impacting patient care in the clinic. At the time, there was little media coverage and many patients were unaware of what was going on. All that quickly changed as I soon found myself sitting across the room from patients and their families, telling them I could not guarantee they would receive their next chemotherapy on time, if at all.

I have been asked to describe what those conversations are like. In one word, they are devastating. These are people facing a life-changing diagnosis who are often still trying to process what all of this means. In that moment when they are told, “There is treatment available but I do not know if and when you can receive it,” the glimmers of hope and possibility quickly fade. Having a clear treatment plan is very powerful and motivating for people, but the fear of the uncertain and unknown is often terrifying.

The shortages have become prevalent throughout the country. A National Comprehensive Cancer Network (NCCN) survey showed that 93% of surveyed cancer centers were experiencing a shortage of carboplatin and 70% of the centers were experiencing a cisplatin shortage. As a result, oncologists have had to make very challenging decisions about chemotherapy utilization and prioritization. The American Society of Clinical Oncology (ASCO) and the Society of Gynecologic Oncology (SGO) have issued excellent clinical guidance for physicians to aid in making treatment decisions. Yet, even exemplary guidance won’t solve the shortages. One of the recommendations is to reprioritize the non-essential use of any antineoplastic medication that is in short supply and to encourage use of an alternative agent or intervention with comparable safety and efficacy, if available. While this is possible for some cancer types, it is not possible for all, and substitutions in treatment plans often come with unknowns in terms of dosing, efficacy, and the potential of increased toxicity. Clinicians are being forced to reconsider entire treatment plans and patients are left frantically wondering how this will impact them in the long run. Unfortunately, the truth is we just don’t know.

The ethical dilemmas posed by these shortages are quite pronounced. In situations of limited supply, oncologists and cancer centers have been forced to make decisions about which patients to prioritize. For example, in the absence of effective alternatives, who receives the infusion of carboplatin that day? Is it the mother of three young kids with platinum-sensitive recurrent ovarian cancer or the grandmother with a newly diagnosed, locally advanced but curable uterine cancer? Both patients desperately need the medication and yet, physicians have had to choose. In a time where physician burnout is already through the roof, the moral injury created by these shortages is inevitably contributing to the ongoing problems. Not being able to deliver the care and treatment we want to provide, and that patients deserve, is truly harrowing.

As time has gone by, the reason for the shortages has become clear. The shutdown at a pharmaceutical company due to quality issues compounded with the inability by other pharmaceutical companies to respond to the increased demand has resulted in the current situation. There have been some short-term solutions put into place to increase production but whether they will have significant impact in terms of what our patients need remains to be seen. What is clear is that carboplatin and cisplatin will not be the only chemotherapy drug shortages we deal with. The loss of profit from the generic drug market in the U.S. is causing companies to decrease or stop drug production, transition their production to overseas (where FDA inspections are less likely), and invest less resources in upgrading factories and focusing on quality. There is a desperate need for incentives to increase generic drug production and to create contingency plans to preempt potential future shortages. These changes will not happen overnight and require continued advocacy and lobbying.

In early June 2023, over 40,000 members of the cancer community — including oncologists, researchers, patient advocates, healthcare professionals, members from industry, and more — gathered in Chicago at the 2023 ASCO Annual Meeting. Groundbreaking research with novel treatments was presented. However, the irony of the situation was not lost on me: we relished in being at the world’s largest oncology stage, while patients back in cancer centers throughout the country anxiously awaited to hear whether the shipment of carboplatin or cisplatin would arrive that week. We speak of the Cancer Moonshot and its goal to reduce the cancer death rate by half in the next 25 years, but how can we do that if we lack the means to provide life-saving generic chemotherapy drugs to patients? The COVID-19 pandemic emphasized how postponing cancer treatment leads to worse outcomes. This is not the time to re-visit this lesson again.

#WeNeedChemoDrugs. I urge you to continue to advocate for our patients and the cancer community as a whole. Until we have long-term solutions, it is only a matter of time before the next e-mail with the next drug shortage arrives.

Eleonora Teplinsky, MD, is head of Breast and Gynecologic Medical Oncology for Valley-Mount Sinai Comprehensive Cancer Care in Paramus, New Jersey. She is a member of the ASCO Advisory Group for the drug shortages.