Navigating Canada's "Postal-Code Lottery"

So far my little handful of posts have been confined to various minor and general issues, but the real purpose of this blog, as I envisioned it, was to help people understand this particular corner of the labyrinthine bureaucracy of the Canadian public healthcare system. Until you have a serious illness (or fear you have one, anyway), the Canadian universal healthcare experiment can look like a grand success. In many ways, it still is: spending half what Americans do per capita on healthcare, we still achieve comparable results in terms of survival rates, and superior results in life expectancy.

At the same time, our bureaucratic morasse is creating many more problems than it solves. At the beginning of the year, the Cancer Advocacy Coalition denounced the multitude of different provincial regulations for cancer treatment as a "postal-code lottery": Canadians get different treatment depending on where they live. There are reasons for this, and I hope to explore them later on. For the moment, let's accept that it's true – and that I'll try to help people understand where they fit into that lottery over the coming months.


Here, to start with, is an example of what the Coalition meant. Exhibit 1 is Cancer Care Ontario's New Drug Funding Program, the list of cutting-edge drugs (read: anything less than a decade or so old) which it funds, in addition to the old standbys like cyclophosphamide, vincristine, and prednisone (the three drugs that make up the venerable CVP protocol). The NDFP includes all new monoclonal antibodies and so forth, for all cancers.

And now, Exhibit 2: the list of protocols approved by the BC Cancer Agency, for lymphoma and myeloma alone.

I'm cheating, of course. The BC list includes all protocols -- including multiple variants on CHOP and CVP/COP (actually the same protocols: vincristine is also known by its original brand name, Oncovin).

Still, if you read carefully, you'll notice some stark differences. Ontario has a grand total of two "new" drugs for treating lymphomas: fludarabine (Fludara) and rituximab (Rituxan), neither of which are actually new anymore. BC has alemtuzumab for CLL/SLL (Ontario just got around to funding rituximab for that condition last year), rituximab, fludarabine, gemcitabine (Ontario only funds it for lung, bladder and pancreatic cancer), ibritumomab (Zevalin), and tositumomab (Bexxar).

It's those last two which intrigue me most, for the moment. Both are several years old now, and both have proven themselves extremely powerful against indolent lymphomas. Ontario went for neither of them: it actually rejected Zevalin, and the jury's still out on Bexxar. Its eligibility requirements for the drugs it does fund are also much more restrictive: for rituximab, for instance, you get one shot, either monotherapy or combination treatment, and then it's no more rituximab for you. Choose wisely!

And so on and so forth. Want to bet which province you're going to want to be in when CAL-101, GA101, brentuximab, epratuzumab, or any of the other exciting products in the pipeline come available in Canada? Of course, B.C. could drop the ball at any time, government funding being what it is. But for the moment, a BC CareCard sounds like a pretty attractive asset, looking on from eastern Ontario as I now am.