Redispensing cancer medicines means caring for the environment

3 billion dollars a year – that is a rough estimation of the value of cancer drug waste annually in the United States which is nearly a half of the yearly budget of the National Cancer Institute of Oncology. Pharmaceutical wastage is not only an economic problem, but it also has an impact on the environment.

Disposal of expired or unused medicines needs to be managed properly to avoid environmental pollution and contamination of surface waters. While every pharmaceutical product comes with its environmental costs in terms of manufacturing, marketing, transportation and delivery to the patient, improper disposal may severely impact on the total amounts of CO2 and other pollutants associated with therapies. As presented by Max Piffoux of Claude Bernard University, Lyon, France, at the ESMO Climate Change Task Force Session taking place during the ESMO Congress 2024, the environmental impact of an anticancer agent, measured as the equivalent of CO2 production, can vary from 1kg for tamoxifen to over 300 kg for a typical immunotherapy for a 1-month therapy.

Although data are lacking to precisely estimate how much CO2 enters the atmosphere because of expired or unused agents, it is known that oral anticancer agents are one of the primary sources of medication wastage in oncology: approximately one-third of patients discontinue these drugs early, with half of them having unused packages of the drug at home (Res Social Adm Pharm. 2019 Jan;15(1):100-105).
Redispensing of medicines unused by patients seems to be a promising solution to reduce waste and environmental impact provided that the tablets were stored properly, keeping their quality and efficacy.
A research group from the Netherlands conducted the ROAD study to assess the feasibility of this approach, and for which findings were recently published in the JAMA Oncology and also presented at the ESMO Congress (JAMA Oncol. 2024 Jan 1;10(1):87-94). In the study, 1071 patients treated with oral anticancer drugs were included in the redispensing programme and 16% of them returned on average two packages of unused drugs. Storage conditions and final quality of returned medicines were approved in nearly 75% of the medicine packages. Following a detailed quality assurance procedure, 228 drug packages were redispensed to new patients, reducing total waste by 68%. The financial benefit was estimated at over 500 euro per patient.

Analysing these findings from an environmental perspective, it may be estimated that the programme led to a reduction of at least 50 tonnes of CO2 equivalent related to the drug manufacturing process, plus additional savings related to unnecessary drug disposal. These figures mean a saving of around 50 kg CO2 equivalent per each patient treated with oral drugs: a small benefit per se, but a substantial one if we consider that millions of patients receive oral anticancer agents.

A second study describes a model of cancer drug repositories where patients can donate their unused drugs, which was established in the State of Michigan, United States (Oncologist. 2024 Mar 14:oyae040). In this programme – involving a consortium of 18 sites joining the The YesRx Network - patients can donate their unused cancer medications, which are later redispensed to people who cannot afford the therapy due to financial toxicity. During a 6-month period, the consortium collected over 125 patient medication donations and dispensed medications valued at 1.3 million dollars to 106 patients. Besides financial and environmental benefit, such programs can help to tackle inequalities in access to therapy.

Despite these virtuous initiatives providing a framework to make oncology more sustainable and environmental-friendly, implementing such approaches in everyday practice can be challenging. In some places such as many European countries, legal constraints do not allow drug reuse outside the experimental setting, and there is an unmet need for more research in the field to drive change. While waiting for better times for a change, everyone in the oncology workforce can do their part to tackle medicine waste. One very concrete action is to carefully evaluate every prescription by asking ourselves simple questions – is it really necessary? Does the patient requires the largest package? Am I prescribing a prophylactic drug “just in case”? With smart prescribing, medical wastage can be reduced together with its environment impact.