Implementing an Oral Cancer Drug Repository Service: Cowell Family Cancer Center

Annual US spending on oral cancer drugs has surpassed $947 million¹ and is expected to increase 12% to 15% annually through 2027.² In many cases, a significant portion of these funds come directly from patients.³ The out-of-pocket costs for the top 54 oral chemotherapy agents in 2019 were projected to exceed $10,000 per fill annually for patients enrolled in Medicare Part D plans.³

Consequences of the High Cost of Cancer Treatment

The consequences of such costs are felt in various ways, including directly and indirectly. Approximately 49% of patients who are receiving treatment for cancer in the United States have financial burden, with wide-ranging and disparate manifestations depending on critical factors such as age, ethnicity, insurance coverage, and marital status.⁴ Patients who have financial toxicity have more than twice the odds of worse self-reported physical, mental, emotional, and social functioning, as well as increased rates of depression, anxiety, and early mortality.^5-10

The high cost of chemotherapy is exacerbated by excess drug waste within the US healthcare system.¹¹ It is estimated that 25% (approximately $765 billion) of annual US healthcare spending is wasted each year, and approximately 740 tons of unused medications may be unnecessarily discarded by US nursing homes on an annual basis.^11,12 An analysis of drug waste from a regional cancer center concluded that, over a 3-year period, 41% of patients who received prescriptions for everolimus, sunitinib, axitinib, or vemurafenib had wasted at least some of their drug supply.¹³ The reasons for waste were cancer progression (69%), adverse events (13%), patient death (13%), and dose changes (5%). Wasted drug was calculated to have a combined average wholesale price of approximately $250,000 and required more than $2500 in copays for a drug that was not used.¹³

To ameliorate the cycle of increasing costs and waste generation, state and regional governments have enacted legislation that permits the reuse of prescription medication within drug repository programs. As of September 2024, 45 states, Washington DC, and Guam had adopted such legislation, with 29 states having operational programs.¹⁴ ASCO endorses the use of repository programs to mitigate financial toxicity,¹⁵ and emerging data support the viability and benefit of cancer drug repository (CDR) operations.^16,17 Despite this progress, however, notable obstacles, such as burdensome requirements and administration, lack of financial or operational resources, and a lack of public awareness, may impede the routine implementation of these programs.¹⁸

In November 2021, Cowell Family Cancer Center Infusion Pharmacy became one of the only active CDR programs in Michigan. The goal of our study was to characterize the preliminary results of a newly implemented CDR at a community cancer center, share a framework for repository implementation, and disseminate lessons broadly to accelerate participation in repositories regionally and nationally. Our primary objective was to characterize the patients served through the repository and share the corresponding US dollar value of dispensed medications. A secondary objective was to characterize the US dollar value of medication saved from the unnecessary disposal of drugs through the use of the repository.

Our Approach

This single-center, observational study was conducted at Cowell Family Cancer Center in Traverse City, MI, from November 2021 through September 2023. Cowell Family Cancer Center is a community cancer center operating within the Munson Healthcare System to serve patients throughout the northwest region of Michigan’s lower peninsula. A total of 14 clinical oncology pharmacists work alongside 9 medical oncologists, 1 gynecologic oncologist, and several advanced practice providers to service approximately 3000 new patients annually.

As a participating site in the Pharmacists Optimizing Oncology Care Excellence in Michigan collaborative quality initiative,¹⁹ 2 of the 14 clinical oncology pharmacists within Munson Healthcare are embedded within ambulatory clinics that provide patient education for each new oral chemotherapy regimen. Each of these education encounters includes brief information about the CDR, criteria for inclusion of previously dispensed medications and supplies (Table), and instructions on how to donate and receive medications through the repository, if applicable. In addition, printed materials were created for patient distribution and are included in every new patient information packet.

Because CDR prescriptions are not a substitute for a long-term supply of medication, intentional and transparent communication between the pharmacy and financial navigation services was a special priority to ensure that there is a viable plan for therapy after each CDR dispense. Finally, an electronic CDR inventory was created using the site’s existing inventory management software, which allows separate tracking of all CDR items.

Prioritizing CDR Allocations

An important aspect of the Michigan law requires that allocations through a CDR be prioritized vis-a-vis certain criteria. The first priority is that the drug goes to individuals who are uninsured or who lack coverage for the medication, including patients who do not qualify for manufacturer or institutional copay assistance or who cannot afford their medication despite such copay assistance. The second priority is to individuals who are enrolled in Medicaid, Medicare, or any other public assistance healthcare program. The third priority is to all others who have been diagnosed with cancer.

A scoring tool was used by the site to objectively evaluate candidates for new regimens, with higher scores indicating a greater priority for dispensing. The scoring tool is designed to be used in collaboration with the medical oncologist and pharmacist when needing to allocate scarce drug amongst multiple patients who are not otherwise prioritized by state law. Anticipating ambiguity in such decisions, a standing ethics committee has also been created to guide the allocation of the donated drugs. Notably, this approach to CDR operation attempts to minimize the use of a first-come, first-served approach, which is thought to further advantage those patients with more privilege at baseline.^21,22

Who Used the Repository?

Most (n=20; 57.1%) of the 35 patients who received drugs through the repository were unable to afford the copay for their medication and were seeking alternate payment methods for coverage. The remainder of the patients (n=15; 42.9%) were having difficulty acquiring a supply of medication because of insurance or processing delays. Of the 35 patients served, most (n=28; 80%) received health insurance through Medicare or Medicaid, although 10 patients with Medicare did not have active prescription drug coverage. A total of 2 patients expressed a need for CDR services and were ineligible for the program because of out-of-state residency.

What We Achieved

Cowell Family Cancer Center received regulatory approval for CDR operation from the Michigan Board of Pharmacy in November 2021 and received its first donation of oral chemotherapy in December 2021. By November 2023, 6 additional sites within Munson Healthcare received the Board of Pharmacy’s approval for CDR operation, for a total of 7 CDR sites spread throughout the regional Munson Healthcare System. All sites share centralized inventory and tracking of CDR medications.

As of September 30, 2023, the system repository accepted a total of 96 drug donations, consisting of 56 unique medications, valued at approximately $1.64 million. The repository has dispensed 38 prescriptions that were valued at more than $490,000 to 35 patients and transferred medications with a value of $55,800 to separate repositories for an additional 5 patients. All medication values are reported in US dollar wholesale acquisition cost (WAC) at the time of dispensing per Micromedex’s RED BOOK data.

In addition to the financial savings for patients, the RED BOOK data suggest that CDR operation may have prevented the unnecessary disposal of approximately $1.53 million of medication. WAC pricing is not indicative of actual consumer cost, but using more accurate methods of cost comparison, such as prescription copays, was outside the scope of this study. As a bridge to sustainable therapy, CDR medications also decreased the aspects of opportunity cost by providing direct medication supply, simplifying the supply chain process, and minimizing wait times.

CDR Sustainability

During the first 18 months of the CDR’s operation, more medications were donated to the CDR than were dispensed to patients. This resulted in a considerable inventory of drugs and contributed to the expiration of 6 donated medications (alpelisib, imatinib, lenvatinib, pancrelipase, regorafenib, and sunitinib) valued at approximately $114,000. To prevent waste, CDR stakeholders have begun to work on multiple countermeasures to maximize patients’ benefit from the CDR: In select circumstances, repository personnel now proactively contact patients to offer CDR supply of drugs that may soon expire. Additionally, Michigan now has a statewide, centralized CDR that was created in 2023 to expand the impact of regional CDR programs. Our CDR participates in this collaboration to connect CDR drug to more patients throughout Michigan.

Closing Remarks

The preliminary results from this single-center study show that drug repositories may function to prevent drug waste and provide a bridge supply of medications to high-risk patients who are underinsured. Cancer drug repositories may be successful even in rural communities, but further work is needed to characterize the best-practice models of a repository’s operation. A centralized, integrated, and statewide repository now exists in Michigan with the goal of increasing health equity and maximizing patient benefit. This work is needed alongside the equally important work of increasing access to affordable cancer care in our communities.

A longer version of this article with comprehensive data reporting was published in the Journal of Hematology Oncology Pharmacy, April 2025 Vol 15, No 2.

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