SB 535 would prohibit health care insurers that already cover biomarker testing from requiring prior authorization.
By AJ Patel, Special to CalMatters
AJ Patel is a legal analyst from Orange County and a lung cancer survivor.
Quite literally, biomarkers saved my life.
It all started with a ticklish feeling in the back of my throat, an annoyance that wouldn’t go away. After weeks of discomfort, to the point where I had to see a doctor, I heard those three words that no one wants to hear: “You have cancer.”
Two growths on my lungs were massive, and a brain scan showed tumors so large that my oncologist was surprised I could even walk. I had Stage IV lung cancer, and my doctors unanimously agreed the outlook was bleak. In fact, without immediate treatment, I was told I had about six more months.
Not enough people understand that when you’re diagnosed with any advanced stage cancer, there almost always is no such thing as a complete cure. Sure, there are enormously potent drugs that help treat the cancer and even give you more time but with them comes long-term permanent effects. The shooting pain of neuropathy in your hands and feet robs you of sleep. Brain metastases render whole parts of your body useless. You can’t drive, you can’t use a knife or fork – at least that’s what it was like for me. That’s where biomarkers entered the picture.
Every form of cancer has mutations, or biomarkers. Identifying them can make it easier to categorize and help doctors choose what course of treatment to use – such as targeted therapy, immunotherapy or chemotherapy.
Like snowflakes, no forms of cancer are identical, so biomarker testing at diagnosis is absolutely critical. In a testament to how far lung cancer treatments have come, there was a time when chemotherapy or radiation were our only options – biomarker testing completely changed that and now provides many different treatment options.
In my particular case, the results of biomarker testing were lifesaving. Specifically, I tested positive for a biomarker known as the ROS1 mutation, which meant that my cancer could be treated with a revolutionary targeted pill. This reduced the size of my tumors to the point that I am now in complete remission.
While biomarker testing saved me from lung cancer, all advanced stage cancer patients must be able to have access to biomarker testing, and it is essential that it be timely and affordable. The sooner information on the existence of biomarkers is available, the sooner doctors can begin, in some cases, life-saving measures to treat the patient. Delays in biomarker testing can literally mean the difference between life and death for many cancer patients.
Senate Bill 535, introduced by state Sen. Monique Limón, a Democrat from Santa Barbara, would prohibit health care insurers that already cover biomarker testing from requiring prior authorization for biomarker testing for plan members with advanced or metastatic Stage III or Stage IV cancer. I shudder to think how many required “prior authorizations” have cost people their lives by creating critical delays in gaining access to biomarker testing.
This legislation also addresses an important equity issue that utilization management tools like prior authorization often raise. Most cancer patients – more than 80% – are treated at community-based cancer centers which may not have the adequate staff to manage the administrative burden of prior authorization.
Eliminating the administrative delay placed on health clinic staff for plans that are already covering biomarker testing could have a downstream positive impact on patients treated at lower-resourced cancer centers. SB 535 will have a positive impact on cancer patients, which is why it has received unanimous bipartisan support, and is now waiting for Gov. Gavin Newsom’s signature.
On behalf of all advanced stage cancer patients in California, I strongly urge the governor to sign SB 535 and eliminate the prior authorization rule for health care plans that cover biomarker testing.
We must have timely and affordable access to diagnostics that inform treatment decisions for advanced stage cancer patients. Every Californian diagnosed with advanced stage cancer where time is of the essence in selecting treatments deserves this – and absolutely nothing less.