Bill Niblock has the same cancer as hundreds of others in Canada, but he can't obtain identical treatment. Because he lives in Ontario, he will receive a lesser therapy, making him the victim of what experts label a geographic lottery.
Unequal access to cancer drugs - a long-standing issue for patients and oncologists - was to be remedied with the creation of the Joint Oncology Drug Review, to which all provinces but Quebec belong. Despite JODR's formation in March, 2007, the funding of some cancer drugs remains unequal across the country.
"Here in Canada, it's still a postal-code lottery for cancer drugs," said Bill Hryniuk, past chairman of the Cancer Advocacy Coalition of Canada.
But Helen Stevenson, executive officer of Ontario Public Drug Programs, defended the JODR's efforts, saying eight drugs have so far been funded by most provinces on its recommendation.
However, that figure only represents one-third of the total number of drugs reviewed. And when asked why some provinces fund drugs that others do not, Ms. Stevenson noted that "quite often, it is an affordability issue."
That is certainly the issue for Mr. Niblock, 68, who can't afford the $22,000-a-year price tag for the drug to treat his chronic lymphocytic leukemia (CLL), a blood and bone marrow disease.
If he lived out West, he would be prescribed rituximab in British Columbia, Manitoba and Saskatchewan. And if he resided farther East, he would have a greater chance of obtaining it: Newfoundland, Prince Edward Island, New Brunswick and Quebec all provide it on a case-by-case basis.
But because he lives in Hamilton, Ont., Mr. Niblock cannot obtain the drug his oncologist wants him to take, as it is under review for funding. At present, Ontario only funds it for some lymphoma patients and rheumatoid arthritis sufferers. Alberta and Nova Scotia also don't fund rituximab, despite new data showing CLL patients can live longer if they take it with chemotherapy.
"It seems so unfair," Mr. Niblock said.
In a 2009 report, the Cancer Advocacy Coalition described access to new and expensive drugs as "one of the most urgent problems cancer patients face." That report also looked at 24 cancer drugs approved for 18 new conditions and found Ontario was tied with New Brunswick for funding the fewest - only six as of Dec. 25, 2007, the most recent data available. By contrast, British Columbia funded 20 of those medications.
B.C. began funding rituximab for eligible CLL patients in 2004, when trials suggested it helped, according to Laurie Sehn, a hematologist-oncologist at the BC Cancer Agency.
"The early evidence suggested it [rituximab]appeared to be offering an advantage and we were prepared to fund it for patients, pending clinical trials that would provide the definitive answer," Dr. Sehn said. "Now they've actually pointed to the fact that this was an appropriate thing to do."
If they don't have insurance, they are just out of luck James Gowing, a hematologist-oncologist and chairman of the Cancer Advocacy Coalition
To many, the discrepancy seems baffling: How can the medical evidence be strong enough to warrant the funding of a drug in one province but not in another? To patients facing life-threatening illnesses, unequal care begets unequal outcomes: Some patients will live longer simply because they have access to better treatment.
"I know patients who have relocated to get the drug," said Elizabeth Locatelli, executive director of the CLL Patient Advocacy Group. "They have gone out to B.C."
Still, many others simply go without, unable to afford the treatment.
"If they don't have insurance, they are just out of luck," said James Gowing, a hematologist-oncologist based in Cambridge, Ont., who is also chairman of the Cancer Advocacy Coalition. "It's standard treatment around the world; it's standard treatment in every civilized country."
Michael Hallek, a professor at the University of Cologne in Germany, led the most recent study of CLL patients, proving for the first time several weeks ago that patients live longer on the drug. Dr. Hallek said in an e-mail that the use of rituximab should now be considered the standard of care; most patients in developed countries receive it.
Clinical hematologist Ronan Foley said his patient, Mr. Niblock, should start on the drug within the next month or two. If he waits too long, he could become too ill to start using it.
"There needs to be a process to crisply determine which drugs should be available based on rigorous, high-quality clinical data," said Dr. Foley, director of the stem cell laboratory at Hamilton Health Sciences Centre. "… As a hematologist, there is always this unsettled sense that some [provinces]are providing the drug and others aren't."
Mr. Niblock, who will receive chemotherapy without the rituximab, wants to live as long as possible, as many people rely on him: His wife, daughter and two grandchildren all live with him.
Without the drug, "I will fatigue away and it will overcome my system and it will kill me," Mr. Niblock said. "And then it's going to cost money again, to get buried."
What is chronic lymphocytic leukemia?
It is a slow-growing cancer that occurs when stem cells in bone marrow make too many lymphocytes.
Although lymphocytes help the body fight infection, when they become too numerous, they push out platelets and healthy white and red blood cells.
According to the Canadian Cancer Society, 1,829 Canadians were diagnosed with CLL in 2005, the latest figures available.
What is rituximab?
It's a monoclonal antibody that targets a protein called CD20 on the surface of leukemia cells, where it sticks to that protein. The cells of the immune system then pick out those marked cells and kill them. CD20 is on all fully developed B cells - a type of white blood cell.
Newly forming B cells don't have that protein and therefore aren't killed by the drug. That means the body can produce healthy B cells and their numbers can return to normal several months after treatment.
What does the science say?
The latest study of 817 patients in 11 countries found that they live longer when on the drug and receiving chemotherapy, compared to those receiving chemotherapy alone.
Specifically, 84.1 per cent of patients with previously untreated CLL who received rituximab plus chemotherapy [fludarabine and cyclophosphamide]were alive after more than three years of follow-up, compared with 79 per cent of patients who received chemotherapy alone, according to the study released in early December at the American Society of Hematology meeting in New Orleans.
As well, after more than three years of follow-up, patients who received rituximab plus chemotherapy had a median progression-free survival - the length of time during and after treatment in which a patient is living with a disease that does not get worse - of 51.8 months, compared to 32.8 months for those who received chemotherapy alone.
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