A GIFT OF TREATMENT.

Byline: Tim Christie The Register-Guard

After a rough couple of weeks, Barbara Wagner finally got some good news Monday.

Last month, she found out that her lung cancer, which had been in remission for about two years, had come back. After her oncologist prescribed a cancer drug that could slow the cancer growth and extend her life, Wagner was notified that the Oregon Health Plan wouldn't cover the treatment, but that it would cover palliative, or comfort, care, including, if she chose, doctor-assisted suicide.

Then, on Monday morning, a representative of the pharmaceutical company called Wagner and told her it would provide the medicine for free. Wagner said she didn't know whether to laugh or cry, so she did both.

"I am just so thrilled," she said. "I am so relieved and so happy."

Wagner had to rely on the charity of a drug company because the Oregon Health Plan wouldn't cover her treatment.

"Treatment of advanced cancer that is meant to prolong life, or change the course of this disease, is not a covered benefit of the Oregon Health Plan," said the unsigned letter Wagner received from LIPA, the Eugene company that administers the Oregon Health Plan in Lane County.

Officials of LIPA and the state Health Services Commission, which sets policy for the Oregon Health Plan, say they've not changed how they cover treatment of recurrent cancer, only clarified the rules.

But local oncologists say they've seen a change in policy, and that their Oregon Health Plan patients with advanced cancer no longer get coverage for chemotherapy if it is considered comfort care.

"It doesn't adhere to the standards of care set out in the oncology community," said Dr. John Caton, an oncologist at Willamette Valley Cancer Center.

Coverage limitations

Numerous oncology studies have found that chemotherapy, used in a palliative setting, decreases pain, decreases time spent in the hospital and increases quality of life, Caton said.

When the Oregon Health Plan was established in 1994, it was expressly intended to ration health care. A prioritization list was drawn up, with diagnoses and ailments deemed most important - pregnancy, childbirth, preventive care for children - placed at the top of the list. At the bottom are procedures such as cosmetic surgery, which would not be covered.

"We can't cover everything for everyone," said Dr. Walter Shaffer, medical director of the state Division of Medical Assistance Programs, which administers the Oregon Health Plan.

"Taxpayer dollars are limited for publicly funded programs. We try to come up with polices that provide the most good for the most people."

Most cancer treatments are high priority on the list, Shaffer said. "But there's some desire on the part of the framers of this list to not cover treatments that are futile, or where the potential benefit to the patient is minimal in relation to the expense of providing the care."

Dr. David Fryefield, medical director of the Willamette Valley Cancer Center in Eugene, said Oregon Health Plan policies haven't kept up with advances in oncology.

"The prioritization list and the definitions and tests that are applied are 15 years old and not appropriate in today's practice of oncology," Fryefield said. "There are so many more targeted therapies that specifically target the cancer and have very few side effects."

Darren Coffman directs the state Health Services Commission, an 11-member panel of doctors, social service workers, public health nurses and consumer representatives that sets policy for the Oregon Health Plan. One long-standing rule of thumb developed by commission is known as the 5-year, 5 percent rule: Any treatment that doesn't provide at least a 5 percent chance of survival after 5 years won't be approved.

Last fall, he said, the commission added an example to its guidelines, stating that coverage of palliative care for patients with advanced cancer would not include chemotherapy or surgical intervention intended primarily to prolong life or alter disease progression.

"We wouldn't consider that to be a change in policy," he said. "They wanted to point out examples of things that wouldn't be covered to be more explicit."

Palliative care is intended to provide comfort and relieve symptoms such as pain and shortness of breath for patients with a fatal prognosis.

Dr. Som Saha, a Portland internist and chairman of the Health Services Commission, said the instances where chemotherapy is the only way to relieve someone's symptoms are relatively rare.

"Chemotherapy is relatively costly, and relatively toxic," he said. "And sometimes it's the case where people will give chemotherapy with the intent of prolonging life when the extent of prolonged life is not substantial."

Cancer drugs are notoriously expensive, often costing $3,000 to $6,000 a month, oncologists say. Tarceva, the drug that Wagner's oncologist prescribed, costs $4,000 for a month's supply.

Fryefield said chemotherapy today often falls in a gray area between comfort care and a cure. It can both extend life and maintain a patient's quality of life, he said.

Many lack basic care

Consider the case of Randy Stroup, a 53-year-old Dexter resident who recently found out the Oregon Health Plan wouldn't cover mitoxantrone, chemotherapy for prostate cancer.

Stroup's oncologist, Dr. Andy Monticelli, said mitoxantrone, the first chemotherapy approved for prostate cancer, has been around about 10 years, and the benefit of using it for recurrent prostate cancer has been to shown to be "not huge, but measurable."

"It would probably be of minimal benefit for a relatively short duration of probably several months," he said.

But while the drug may not extend a patient's life by very long, it does help make those last months more bearable by decreasing pain, he said.

Stroup said he wants what ever time he can get.

"My perspective is, if it works it works," he said. "What is six months of life worth? To me it's worth a lot.

"This is my life they're playing with," he said.

Commission members say they feel the weight of people who are denied coverage under the health plan.

"It is impossible not to think of those individuals and the suffering they're going through," Saha said. "But we also need to think about the hundreds of thousands of Oregonians who don't have access to even basic health care. We have to keep an eye on those people as well."

Wagner said she was devastated when she found out that the Oregon Health Plan wouldn't cover Tarceva, the drug that her oncologist ordered when her lung cancer came back.

"I think it's messed up," Wagner said, bursting into tears.

She was particularly upset because the letter of denial said that doctor-assisted suicide would be covered.

"To say to someone, we'll pay for you to die, but not pay for you to live, it's cruel," she said. "I get angry. Who do they think they are?"

The language in the letter referring to Oregon's Death with Dignity Act comes out of the Health Service Commission's statement of intent under examples of comfort and palliative care, said Dr. John Sattenspiel, senior medical director for LIPA.

"I understand the way it was interpreted," he said. "I'm not sure how we can lift that. The reality is, at some level (doctor-assisted suicide) could be considered as a palliative or comfort care measure.

"We had no intent to upset her but we do need to point out the options available to her under the Oregon Health Plan."

Wagner, 64, lives in a low-income apartment in Springfield with her Dachshund, Chachi. She's a divorced mother, grandmother and great-grandmother, retired from driving a school bus for the Springfield School District and working as a waitress at a Coburg truck stop.

She was a life-long smoker, quitting when she was diagnosed with non-small cell lung cancer about two years ago. Her oncologist, Dr. Jae Lee treated the cancer with chemotherapy and radiation and it went into remission, she said.

In early May, a CT scan revealed her cancer was back and Lee prescribed Tarceva, the brand name for erlotinib, a cancer drug in pill form taken once a day. Studies show the drug increased the median survival rate for patients with advanced non-small cell lung cancer from 4.7 months to 6.7 months. One-year survival for patients who took Tarceva was 31.2 percent, compared to 21.5 percent for patients who took a placebo.

Every patient, and every cancer, is different, and Lee said Wagner already has lived much longer than a typical lung cancer patient. Her cancer doesn't grow rapidly, and he thinks Tarceva would help her.

Lee appealed to Genentech, the company that markets Tarceva in the United States, to cover Wagner's medication. On Monday, Wagner got the call from Genentech. She was told they would cover the drug for a year, at which time she could re-apply. She expects to receive a visit today from FedEx.

"It's fantastic," she said. "I can't wait to start the medication."