Chemotherapy drugs cisplatin, carboplatin, oxaliplatin and ifosfamide are in shortage again, but five health systems are managing without the treatment delays and drug rationing that defined 2023.
Shortages of the drugs have been straining hospital supply chains since June, with data showing some hospitals filling only 38% of ifosfamide orders and about two-thirds of cisplatin orders. The same drugs have been driving care disruptions, leading to “severe negative impacts” on patient outcomes, according to some oncologists.
“This is our seventh or eighth wave of national shortage challenges in more than a decade in oncology pharmacy,” Alexander Quesenberry, PharmD, pharmacy director at Memphis, Tenn.-based Baptist Cancer Center, told Becker’s. Fortunately, Dr. Quesenberry said Baptist Cancer Center hasn’t had to change how it allocates or schedules any of the four drugs, crediting the system’s size and buying power — including direct accounts with manufacturers that let Baptist bypass the wholesaler and pick up drop-shipped or short-dated product directly when needed.
Other systems’ leaders have echoed similar situations. Elaine Huang, PharmD, associate chief pharmacy officer at Seattle-based UW Medicine, hasn’t made broad changes, though her team is primed to act once inventory crosses a defined “shortage threshold.”
Kelley Curtis, PharmD, chief pharmacy officer at Boise, Idaho-based St. Luke’s Health System, hasn’t delayed treatment for patients needing cisplatin, carboplatin or oxaliplatin, and reports only minor disruptions on treatments requiring ifosfamide.
Nilesh Desai, chief pharmacy officer at University of Miami Health System, has seen a handful of delays for new inpatient ifosfamide admissions, but no disruption to outpatient care.
Wafa Samara, PharmD, vice president and chief pharmacy officer at Duarte, Calif.-based City of Hope, is watching inventory closely enough that intervention hasn’t been necessary yet.
Sourcing and substitution strategies
Avoiding disruption to patient care has taken work, though. Baptist Cancer Center has started using Kyxata, a 505(b)(2) carboplatin alternative, for some patients — a shift Dr. Quesenberry said traces back to the economics driving the shortage cycle itself.
Generic chemo drugs carry thin manufacturer margins, which is part of why supply cushions are so shallow to begin with. Reimbursement compounds it: Medicare’s packaging threshold for outpatient oncology infusions doesn’t separately reimburse anything priced under $140 a dose, so a $100 generic can go effectively unreimbursed. Because 505(b)(2) products can be priced above that line, they draw reimbursement a generic wouldn’t get — even though, clinically, Dr. Quesenberry said there’s no real difference from the generic; sometimes it’s simply a different concentration or a pre-mixed suspension rather than a powder. The remaining friction is getting clinicians and patients to switch, since some insurers still require step therapy first, though most are waiving that given the shortage, he said.
Baptist Health, based in Louisville, Ky., has started using Kyxata as well. Brandon McLain, PharmD, chief pharmacy officer, said the system has directed new patients starting treatments to the drug while reserving conventional carboplatin supply for patients already established on therapy. Dr. McLain said he has also pointed patients to manufacturer-sponsored assistance programs to offset the cost difference.
Sara Moran Smith, PharmD, oncology pharmacy program manager at Minneapolis-based Allina Health, said that while supply for carboplatin, cisplatin and oxaliplatin has been sufficient enough to avoid widespread treatment modifications or delays, ifosfamide is in critical shortage. Dr. Moran Smith and her team are currently prioritizing use of ifosfamide for select patients and identifying clinically appropriate alternative treatment regimens.
“Rationing oncology drugs is one of the most challenging situations health systems face,” she said. “Organizations must evaluate disease state, treatment intent, available alternatives and anticipated outcomes while ensuring decisions are applied consistently and fairly. This requires a transparent ethical framework, multidisciplinary review and strong support for clinicians who may experience significant moral distress when scarce resources limit treatment options.”
St. Luke’s has combined direct manufacturer allocations, internal inventory redistribution and vetted secondary sourcing with centralized purchasing and weekly demand forecasting, Dr. Curtis said. Miami has relied on secondary wholesalers, its GPO and select third-party wholesalers rather than therapeutic substitutions, backed by close systemwide coordination, according to Mr. Desai. City of Hope swapped in an alternative carboplatin product without restricting use by indication, and is using a different ifosfamide formulation while reserving the on-shortage version for patients at higher risk of neurotoxicity, Dr. Samara said.
However, none of it has been as severe as 2023, not because the underlying supply fragility has been fixed, but because health systems have built more muscle for it.
Broader access to multiple manufacturers for direct allocations has helped at St. Luke’s, Dr. Curtis said, though she’s still watching ifosfamide closely, echoing the uncertainty European regulators have flagged regarding when the ifosfamide supplier’s German facility returns to full capacity.
The 2023 crisis pushed Miami to build reserve inventory targets and start regular systemwide shortage meetings, Mr. Desai said. Having alternative products already in place has given City of Hope more flexibility and faster response than it had in 2023, Dr. Samara said.
What would help most
Transparency is the fix many in the industry support. Dr. Huang and Dr. Samara both want earlier, clearer communication from manufacturers about disruptions before they hit.
Dr. Huang said FDA mandates may be necessary to make that stick, and flagged 340B implications for safety-net and academic centers already running on thin margins. Mr. Desai’s policy list goes furthest: government incentives to stand up temporary domestic manufacturing lines, expanded FDA authorization for science-backed expiration date extensions, mandatory early FDA notification of manufacturing interruptions, and tighter regulatory monitoring to prevent price gouging — asks that track closely with the FDA’s own playbook from 2023, when the agency authorized temporary cisplatin imports from a Chinese manufacturer to ease that shortage.
“The recurring shortages of older generic oncology drugs highlight a fundamental lack of resiliency in the supply chain,” Dr. Moran Smith said. “These products often have very thin profit margins, leaving few manufacturers in the market and little capacity to rapidly increase production when disruptions occur. Hospitals can manage the consequences of shortages, but they cannot solve the root cause. Meaningful long-term solutions will likely require national policy interventions that incentivize domestic manufacturing, increase supply redundancy and create greater resilience across the generic drug market.”
Dr. Curtis shared similar sentiments and wants more equitable allocation practices from manufacturers, GPOs and wholesalers earlier in the process, calling the four drugs “the backbone of many oncology treatment regimens.”
Dr. Quesenberry’s version is more granular. Manufacturers being upfront about the scale of a shortage, and giving front-line staff running timelines and updates, makes the biggest difference, he said.
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