Experts Provide Key Perspectives on the US Cisplatin/Carboplatin Shortage

Heather Wakelee, MD, FASCO

The ongoing shortage of cisplatin and carboplatin not only has the potential to negatively affect therapy decisions and access to treatments for patients, but it is arguably a preventable crisis, according to several clinicians, who say these shortages elucidate the need for large-scale policy changes that introduce redundancy and account for potential supply chain issues.

At the 24th Annual International Lung Cancer Congress®, oncologists from various institutions were interviewed by OncLive® about the ongoing platinum chemotherapy shortage in the United States.

Those interviewed included:

• Heather Wakelee, MD, professor of medicine, chief, Division of Oncology, Stanford University School of Medicine, deputy director, division chief, Medical Oncology, Stanford Cancer Institute, president, International Association for the Study of Lung Cancer
• Karen L. Reckamp, MD, professor of medicine, director, Division of Medical Oncology and Lung Institute, Cedars-Sinai Medical Center, associate director, Clinical Research, Cedars-Sinai Cancer Institute
• Edgardo Santos MD, FACP, FCCP, clinical affiliate associate professor, Florida Atlantic University, treasurer, Florida Society of Clinical Oncology
• Millie Das, MD, clinical associate professor, medicine/oncology, member, Stanford Cancer Institute, chief, Oncology, Palo Alto VA Health Care System, member, VA national Lung Cancer Working Group, Lung Cancer Precision Oncology Program
• Edward Kim, MD, MBA, physician-in-chief, City of Hope Orange County, vice physician-in-chief, City of Hope National Medical Center.
• Erminia Massarelli, MD, PhD, MS, co-director, Lung Cancer and Thoracic Oncology Program, section chief, Thoracic Oncology, associate professor, Department of Medical Oncology & Therapeutics Research, City of Hope
• Lyudmila Bazhenova, MD, medical oncologist, professor of clinical medicine, University of California San Diego Moores Cancer Center.
• Solange Peters, MD, PhD, full professor, chair, Medical Oncology, Thoracic Malignancies Programme, Department of Oncology, University Hospital of Lausanne
• Tony S.K. Mok, MD, BMSc, FRCPC, FASCO, Li Shu Fan Medical Foundation Professor of Clinical Oncology, chairman, Department of Clinical Oncology, The Chinese University of Hong Kong

Below, Wakelee, Reckamp, Santos, Das, Kim, Massarelli, Bazhenova, Peters, and Mok discussed how their institutions may have been affected by the shortages and what they are doing to navigate any resulting challenges to adequate patient care.

Platinum Shortage Continues to Concern Clinicians at Many Institutions

Wakelee: In the United States, we've been having a platinum shortage, which has been very, very difficult because it has impacted patient care significantly. Lots of discussions [are happening] about why that might be. We're in a world where we can get outrageously expensive medications for patients with a sometimes marginal benefit, and yet for the proven drugs that aren't so costly, there are shortages. That really [shows us] where market forces can have a negative impact. It's on all of us to make sure that as we're striving to get newer, better drugs, we’re also thinking about what we are doing to actually help the patients. [We need to] make sure that in this race [for newer drugs], we don't forget to take care of the standard drugs, the medications that we know make an impact, the building blocks upon which these other things are added.

Reckamp: We've all been very concerned about the drug shortages of carboplatin and cisplatin. We have instituted measures to monitor our supplies on a weekly and monthly basis, based on what we previously used. We have prioritized curative regimens, and we rounded potentially to the lower dose to save vials. However, for the most part, we've been able to treat our patients, fortunately. To have drugs that are so widely used and potentially curative for people not be unavailable is a scary thought and is a difficult conversation to have with patients. It is something that concerns us daily.

Santos: The shortage issue of not having cisplatin and carboplatin [for] some diseases in which those medication can be curative has been very impactful. Now things are getting a little bit better with the help of [a foreign] supplier, in collaboration with regulatory entities, and [the crisis is] subsiding. However, 2 months ago, it was very bad. We had to do some adjusting and sometimes make tough decisions. Sometimes, the patient couldn't receive the therapy, or we had to delay the therapy because we didn't have it [available]. It was bad, but things are getting better.

What we need to do, in my opinion, is to have legislation that prevents these things from continuing to happen. There are so many medications that are already have generics, and they are very effective. We cannot allow this vicious cycle to continue. We need to stop that and be sure that the supply chain does not stop. That affects thousands of patients not only here in the United States, but also around the world.

Das: In a lot of situations where we haven't been able to give platinum chemotherapy, these patients are often going to get immunotherapy with either pemetrexed alone or a taxane alone. In my practice, I haven't necessarily leaned more toward the immuno-oncology [IO] combinations because of the platinum shortage. We're all hoping that that shortage is going to be short lived, and we're going to be able to add in the platinum agents to future cycles.

Robust Institutional Strategies Reduce Negative Effects of Shortages in Some Health-Care Systems

Kim:It's probably the fourth time I've encountered [a drug shortage] in my career. There was an etoposide shortage years ago. We give that drug as a curative-intent [therapy] in small cell lung cancer, the area that I treat. We're now seeing this with carboplatin and cisplatin, because one is [low in supply], then you start using the other, and then the other one’s [supply] is short. I will say that most health-care systems, including City of Hope, have been very good at dealing with this. We have made sure we're prioritizing the right setting. We're trying to be mindful of what we use and how we use it. I have personally felt minimal effect from [the shortage], although there have been a lot of emails and a lot of oversight. City of Hope has done a phenomenal job. Kudos to our pharmacy team, as well as our clinic leaders, to help manage this. Although I've heard about it from several colleagues across the country, I believe it has had minimal impact on overall patient care, so kudos to the leaders of these health systems.

Massarelli: We just got very good news: our institution has lifted the restrictions for platinum chemotherapy. There was a the nationwide shortage, and we were very fortunate, because we prioritized some categories of patients when there was really [a significant shortage], but none of our patients on our team were denied drugs. We were able to accommodate the majority of these patients.

We prioritized [patients in the] curative setting and patients who didn't have treatment alternatives. Of course, most lung cancer patients are treated with platinum chemotherapy, so our patients were accommodated, especially the first-line patients. For example, a drug regimen [considered] for first-line advanced NSCLC is the CheckMate 9LA [NCT03215706] regimen, [which] uses less platinum with only 2 cycles. I did use it in some patients, and that was effective. That's how we managed [the shortages], but our institution has now lifted the restrictions.

Bazhenova: We haven't been affected that much. We still have an ability to deliver drugs to your patients. We prioritize, of course, patients who have curable cancer. We also are a little bit lenient in situations where we can easily substitute the drug if there are other alternatives, which is unfortunately not the case in lung cancer. So far, we have not seen that much change in our ability to deliver cisplatin and carboplatin, at least at my institution.

International Perspectives

Peters: This is one of the first shortages that I've seen [only affecting] the United States. Usually, shortages like these are global. I remember we had the etoposide and the bleomycin [shortages], but this carboplatin shortage is not affecting Europe at all, which is quite interesting. We have been writing and working a lot on how to prevent shortages at ESMO. Shortages always affect these drugs which are not [profitable] to produce. This means that production is reduced to the minimal chain of production, the minimal amount of investment [is provided] from the companies producing the agent to reduce the cost, and there is no redundant way to potentially replace either the initial substance or the final drug product.

Usually, it's very limited and considered a minimal investment for the pharmaceutical industry producing the agent, so if anything goes wrong, the drug is not available anymore. There are many [safeguards] that can be put in place politically to avoid shortages, [such as] making the redundancy of a system producing cheap drugs mandatory. This has not been adopted, but we have been writing a lot and asking about how to work on shortages.

In the United States, it is interesting, because [the shortages could] change the whole way you treat patients. More IO/IO combinations [could be used] because you don't have platinum [chemotherapy]. I like the IO/IO [regimen], but not because you're forced to use it. It [should be used] because you think it's the best way to treat your patients. It's irrational that in our very wealthy countries, we don't have the very basic drugs. This is really a policy or a set of rules that have to be fixed. ESMO met ASCO leadership at the 2023 ASCO Annual Meeting. We [must create] a policy working group to force the movement toward a political commitment, because this is just unacceptable for patients.

Mok: There are other producers [of these platinum agents] in Asia that we can [turn] to. A lot of this is due to the approval process of different countries. Up to this point, we don't have a significant shortage of platinum in our countries [in Asia].